Several years ago, we, too, got away from using routine or standing orders per J.C. recommendation. Now they want Read Back on all orders not written by the MD. My question: do you now have a protocol for what to do with all those L&D patients that appear at your door? In other words, we always document: admit for observation, fetal monitor, vag. exam as indicated, urinalysis etc. We put phone order per Dr. X / our name and stamp it with the Read Back stamp. The problem I have is that it may be 1 or more hours before the Dr. is actually notified that the pt. is there. Isn't that false documentation? Our registration dept. will not put the pt. in the computer if we don't send down orders. Based on EMTALA, it's the law that we have to see these pts. and do a Medical Screening Exam so why not have a protocal. Makes too much sense, I guess. Any thoughts?
This year, one of the biggest J.C. focuses was overriding medications. If the order sheet has not been sent down to the pharmacy and the meds. were not 'put into the OmniCell', we had to document on paper that the med. was urgently needed and the order had been reviewed by 2 nurses, both having to sign the form. It was then faxed to pharmacy. Since our babies are not born when our Vitamin K, Erythromycin ointment and Hep. B vaccine is pulled for delivery, the override is done on every baby. Since the order sheet had no name and MR # on it (the baby isn't born yet) pharmacy can not enter the meds.
At what point do you pull your baby meds?