physician orders

[Zar]

Can someone tell me the steps to taking off orders for an admission in long term care. Where each thing goes, where it should be documented etc. Are there any sites or books to help?

[CoffeeRTC, BSN, RN]

Every facility is going to be different. Most if not all LTCs have a pre printed admit orders that you do alot of checking off or circling the preprinted orders. I try to keep all prns on the same page and when I trascribe them I like to keep the am or q day meds on one page pms on one page..just my anal self tho.

What are your specific questions or concerns?

[CapeCodMermaid, RN]

It's simple...follow the same procedure for every order and you won't make mistakes. Read the entire order and make sure you understand it. If any of it is unclear, don't guess, call the doc and get a clarification.

If it is a med order:write the order on the MAR (don't forget to include the order date) and then order the medication, if new from the pharmacy. If it is an order to dc a med, remove the medication from the cart. For any psychotropics don't forget to get consent from the patient or HCP if it has been invoked.

If it is a treatment order: write it on the TAR and order any necessary supplies.

For a lab or xray: fill out the proper requisition form and log it per your facility policy.

When you've finished with all this, note the order and sign your name. You might want to write a nurse's note about any new order and write it in your 24 hour log book.

This isn't rocket science.

[achot chavi]

One piece of advice- never sign off on an order that isn't written correctly- or the dosage is unclear or unusual (i.e.-Tylenol 515 mg or 3500 mg....). All dosage with decimal points have to have a 0 before the decimal point. If you aren't sure ask the pharmacist or doctor, because once you sign it- you're responsible (and can be sued). We've had stories like this in NY.