Published Nov 22, 2010
BacktoBasics
109 Posts
I was just reading another post regarding interventions that should have be completed while waiting to talk to a physican. For instance, getting an ekg, enzymes on a new chest pain patient while waiting for a callback from the physican.
How do you all think computer documention is going to affect this? In my current hospital, we are not allowed to put in orders (and we get in trouble for it too), but yet things won't get done without the orders. Do you put in your own orders? Do you have to attach a physican to it?
BluegrassRN
1,188 Posts
It's the same as before. We enter the orders under the physician, for him/her to co-sign later. In my facility, we have protocols for a lot of events (EKG for CP, etc). In a rapid response, we can enter pretty much for anything the responding team recommends while awaiting the physician's arrival, again according to our protocols.
If you don't have protocols for chest pain, symptoms of hypoglycemia, hypoxia, etc, your facility needs to get those going. I suspect they are already in place, though.
BYW, they told us in our classes that ONLY physicians would be entering orders. THEN later, after implementation, they said that only applied to day shift. If we call someone at night, the nurses are expected to enter the orders.
BrnEyedGirl, BSN, MSN, RN, APRN
1,236 Posts
Same here,..we enter the orders, per protocol, under the docs name, he signs them later.
msjellybean
277 Posts
My facility has a chest pain protocol, where we're allowed to order cardiac enzymes & a stat 12 lead while waiting to hear back from the doc.
ObtundedRN, BSN, RN
428 Posts
In our critical care division, we have lots of standing orders. So we can order it ourselves. It doesn't even need a doc to co-sign since one already signed off on the standing order set.
As for the documentation in the computer, it is entered as being written by the primary doctor. This is done because lab results and other stuff is sent to that doctor's PDA or computer for review later. So if you enter another doctor's name, the correct doctor has to search for it and the wrong doc gets results and left to figure out why.
caliotter3
38,333 Posts
In our critical care division, we have lots of standing orders. So we can order it ourselves. It doesn't even need a doc to co-sign since one already signed off on the standing order set. As for the documentation in the computer, it is entered as being written by the primary doctor. This is done because lab results and other stuff is sent to that doctor's PDA or computer for review later. So if you enter another doctor's name, the correct doctor has to search for it and the wrong doc gets results and left to figure out why.
I've wondered about this when other doctors get involved. One of my supervisors once told me to put both names on the order.
wooh, BSN, RN
1 Article; 4,383 Posts
Yep, we were told the docs would have to enter the orders unless they were scrubbed in, or they were driving.
How long do you think that lasted?