tripletmomma

Hi - I'm new to this board and was looking for a little advice and direction. I work at a LTC facility (been there almost 10 yrs) -- during one of my shifts a physician taking care of one of my patients wrote an order on our 'telephone order' sheet instead of writing it on the 'written orders' sheet. She included the patient's name, order, date and her signature. She neglected to fill out the facility name and address, her full name and phone #. I treated the order as I would any written order and transcribed it into the MAR. My supervisor called this incident to my attention and told me that I should have filled out the facility name and doctor's information on the form. I explained to her that I was taught not to write on a physician's written order (other than noting it was transcribed). She told me I MUST fill out this information if this is ever to happen again. Am I responsible for filling out this information?? Wouldn't I be held liable in a court of law for adding to the written order?? The physician could deny that it was her handwriting and perhaps even deny that she even wrote the order?? Second Question: Does anyone abbreviate -- 'Leave open to air' as LOTA -- my supervisor says this is unacceptable and the whole phase should be written out. I have used this abbrev for years. I have been written up b/c of these 2 incidents and am now being told to take a documentation class!! Any thoughts are appreciated. Also, does anyone know where I can find literature on this. THANK YOU!