Order transcription

Another nurse re-did my transcription

Published

The other day at work I noticed that an order I took off from a doctor had disappeared out of the MAR. It showed I signed off on it and the page that I had a titrate on was ripped out and someone had typed it instead. I don't know why they did it. I made no error! What was worse, the manager who is also a nurse said that there is nothing wrong with doing that, none of the medications had been given yet. I told her that wasn't my point, what if she had made a mistake and I didn't see she changed it? It would fall on me! Anyone else think this is odd? Or against licensing?

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Specializes in Psych (25 years), Medical (15 years).
1 hour ago, PixxieDust said:

 It showed I signed off on it and the page ...

... what if she had made a mistake and I didn't see she changed it? It would fall on me! Anyone else think this is odd? Or against licensing?

Well, PixxieDust, it seems that if this order was not signed off, then the responsibility, and any ramifications thereof, would fall upon the administering nurse.

Back in my days with the two week paper MARs, unit secretaries would often transcribe meds, and  it was the duty of the nurse to sign the orders off.

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3 hours ago, PixxieDust said:

It showed I signed off on it and the page that I had a titrate on was ripped out and someone had typed it instead.

Can you clarify what this means? Does it mean you had titrated the med and signed off having done so, or in some way administered the med and signed off having done so, or...?

Thx.

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Specializes in Travel, Home Health, Med-Surg.

I am not sure I understand but I think what you are saying is that you hand wrote a page in the MAR, signed off on the MD order, and then someone else tore out the (paper) page and replaced it with a new typed order. If so then yeah I think that is strange unless it was unclear to them how you wrote the titration/med order. I can see how you could be blamed for this if something was typed wrong and you already signed off on it. The manager IMO should have re-signed off on the MD order or at least put in a nursing note that she did in fact re-type the hand written order. So yeah, I guess it could be a license thing for you if something had happened with no note from the manager who changed the original MAR. I wouldnt be happy either.

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Specializes in Private Duty Pediatrics.

I don't understand this.

Once something goes into a paper chart, it should not be removed. If it is incorrect, it can be corrected by drawing a line through it, initialing it, and adding a line that corrects it - with the correct and current date, time, and initials or signature.

We don't obliterate or remove anything.

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Kitiger, RN- exactly! Thank you. 
As I stated, I signed off on the order and transcribed on the MAR. The other nurse threw away my titration MAR in the shredder from what I’m thinking. We are a small facility so that’s the only place it could have gone. There was no error. I think she wanted to type it?! Asinine. I’ve always thought that you don’t just throw away a legal document. LOL

Davey Do, actually it was signed off by me. I always sign off on what I transcribe. 

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Specializes in Travel, Home Health, Med-Surg.

So, going forward I would definitely have a chat (diplomatly of course) with the manager about this so it doesnt happen again. She should have already been able to forsee the problems that could arise, but since not, I would explain how that could have gone bad for you and ask her to not do it again, or at least to update the sign off by crossing out your name (as error) and signing hers. 

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Specializes in Hospice, LPN.

I'm also a little confused about the chain of events, whether the order was rewritten on the actual T.O in the chart or if it was on the MAR but another nurse - or anyone - can't write a T.O. if they haven't taken it directly from the provider. That also puts the provider in a weird situation, if they gave it to you and then someone else rewrote it. So, if she had transcribed it wrong that's on her. Is there a protocol in the facility around this? In the places I worked it was the responsibility of the night shift to chart check and make sure all T.Os have been transcribed and implemented correctly on the MAR. Something like that would have been flagged as needing clarification. Orders can't be removed from the chart and shredded. How was the order transcribed into the actual MAR? It sounds confusing. It's always a good idea to document in charting that the order for specific medication/dose was received from provider X, read by and verified, T.O written, entered into MAR. 

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I transcribed an order and put it onto the MAR. There was no error in what I did. I stated that in my original post. I signed off on the order naturally because I am the one who took it off. That MAR disappeared and someone else redid it by typing it. Mine was handwritten. After doing more digging it turns out that a counselor in the place I work took my MAR out and had the other nurse retype it because she didn’t like my handwriting. She is a non-licensed person, the counselor, so I reported her to the administrator. I ended up bringing it to the nurses attention who retyped it and told her that is completely against policy and illegal as far as Throwing away a legal document. Of course she didn’t get in trouble because the administrator is an idiot. I just wanted to be sure that I was correct in reporting them which I think I was.

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Specializes in Critical Care.

The medication order and the MAR are two different things, placing reminders on the MAR that the dose is to be titrated on that day should still be a direction to refer to the actual order for the titration instructions.  Until administered doses are recorded on the MAR it's not actually part of the official chart, it's just a form waiting to become part of the chart.  I hope the process where you work isn't to just copy the order to the MAR, and then copy the copy every time you start a new page in the MAR?

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I am aware that the medication order and MAR are two different things. So I transcribed the order onto an order sheet and it was a telephone order. But that’s not the point at all. The point is that I wrote it on the MAR and that is now missing. The MAR itself is missing,  does that make sense?

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Specializes in Critical Care.
1 minute ago, PixxieDust said:


I am aware that the medication order and MAR are two different things. So I transcribed the order onto an order sheet and it was a telephone order. But that’s not the point at all. The point is that I wrote it on the MAR and that is now missing. The MAR itself is missing,  does that make sense?

Had doses been documented on the MAR you filled out prior to it going missing?

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