Order transcription

[PixxieDust]

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?

[PixxieDust, LVN]

One dose had been given. Yes. But also company policy is that when you sign off on a telephone order or any other order that means you have created a MAR along with it. So therefore if someone goes along and re-does what you have done and makes a mistake, your name is signed to it. I’m certainly glad I went back and re-checked all of my work from the week before or I would’ve not seen that.

[MunoRN, RN]

Your name is signed to the MAR or to the order?

[chare]

On 1/16/2021 at 11:17 PM, PixxieDust said:

[...]

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

"Signed off" where?  The order?  The transcription on the MAR?  Or both?

[JKL33]

I think I understand now.

You signed off the order.

You transcribed the order onto an MAR.

A dose was given (by whom it doesn't matter) and signed off on the MAR that you had created and placed into the chart.

You have 2 concerns:

1. According to the policy of your workplace, the person who signs off the order is responsible for creating the MAR. Therefore, if there is found to be some future problem with the way the MAR appears or was transcribed, the person who is assumed to be responsible will be the person who signed off the order. Thus: If this person who decided to type up the MAR (after you had handwritten an MAR already) had made a mistake in doing so, you would have been responsible d/t having been the one who originally signed off the order.

2. That the MAR is a legal document and cannot just be re-done by someone willy-nilly.

 

Is this a correct restatement of your concerns? If so, my thoughts with regard to the items above:

1. Agree. I would expect that if someone had to re-do the MAR for any reason they would then date/time/sign the original order, and the person responsible for the accuracy of the MAR would be the one who most recently signed/dated.

2. I would believe that an MAR that was simply-retyped but had not yet had any doses noted/administered (or titrated, etc.) is okay to retype as long as #1 is also followed. However, if someone decided an MAR that included administered doses needed to be re-done in any way for any reason, it must be clearly noted as "re-transcribed" by [name] on [date/time]. Any administered doses that need to be transferred to the new MAR must note who originally administered them and should also have a notation that makes it clear that this is not these people's signatures but a transcribed notation.

ETA: I agree with @MunoRN that until doses are administered and noted on the MAR it is not really an issue of a "legal document that is part of the chart and must not be removed." The only legal issue there is that if someone is going to re-do it or use another format (such as a typed version instead of handwritten) it must accurately reflect the associated order. House-policy-wise the second is the issue I've already stated which is that they should also sign off the original order.