nursing home MAR's

[canadianlpngal]

Quick question for anyone at all :) When you have taken a doctor's order and have transcribed it to the MAR, do you write the date and Doctor's name along with the drug order? I have never done this or seen it but one of the nurses at a new place I'm at has insisted this is proper nursing practice....I would welcome any comments??

[TopazLover, BSN, RN]

I have always written the date but not a doctor's name. This is in the original order. I don't see a reason to do so, but I might be mistaken. There are so many regs and they keep changing, best check with your P&P.

[Xbox Live Addict]

Quick question for anyone at all :) When you have taken a doctor's order and have transcribed it to the MAR, do you write the date and Doctor's name along with the drug order? I have never done this or seen it but one of the nurses at a new place I'm at has insisted this is proper nursing practice....I would welcome any comments??

I always wrote the date of the order on the MAR, but I've never heard of the name of the ordering physician written on the MAR itself; that's always on the physician's order form, as well as the nurse that received the order from the physician. The diagnosis for each medication is also supposed to be printed on the order form, and in some facilities, on the MAR, although physicians generally don't bother if they're writing the order during in-facility rounds, and have to be reminded if giving orders over the phone or verbally.

Some nurses are markedly "by-the-book", more so even than administrative nurses, and they may actually know something the rest of you don't - check with medical records or management. They may also have been required to do this at some point at a previous facility, and the old habit became firmly engrained in their practice.

[mondkmondk]

The date, yes, but not the Dr's name because you would write that on your POS. Something new that most places are doing now is adding a dx when transcribing a new med on a MAR, telephone order, and POS. They didn't always used to do that either. Every place has different policies though, so I'd just go along. I learn new stuff every time I go into work.

Blessings, Michelle

[caliotter3]

All I've seen written was the date with the order and the reason/dx for the order. Many times the doctor had to be called back to provide the reason/dx.

[Xbox Live Addict]

The date, yes, but not the Dr's name because you would write that on your POS. Something new that most places are doing now is adding a dx when transcribing a new med on a MAR, telephone order, and POS. They didn't always used to do that either. Every place has different policies though, so I'd just go along. I learn new stuff every time I go into work.

Blessings, Michelle

The DX is increasingly becoming a requirement for Medicare and Medicaid; they want some justification for why they're being asked to pay for a medication. Also, they are requiring more checks on whether the patient's health condition justifies continued use of a certain medication, in order to cut down on overmedication and the adverse effects associated with it.

[nursiemellie]

We only write the medication, time, route, dose, and diagnosis. MD names are on the physician order form.

[infectionRN]

In the right hand corner on the mar, we write the date and our initials upon transcription of the order.