Signing orders off

[CopperEmerald]

Just curious, but what is your workplace policy on signing/noting orders? Can any RN/LPN note orders or should it be the nurse verifying the order?

[tokmom, BSN, RN]

It's the nurses only at our facility. You don't sign them off for another nurse, unless you specifically took them off.

[NurseStephRN]

i honestly don't know the policy at my hospital, but i can tell you that on my unit's day shift sometimes the charge nurse signs off orders for the primary nurse and the (sometimes) lets them know. I personally hate it, but i guess they do it in order to get orders checked off and away from the secretary's area. whenever i go in to help out on day shift i specifically ask the charge to not check off my orders. how am i supposed to know if new orders came in if you signed it off and put the chart away?

[pers]

Our policy is that an RN must verify and note the order. If there is a charge, she or he verifies/notes and then provides a copy to the nurse caring for the patient. On nights, the RN who gets a chance first will verify and note new orders if there is an LPN who needs it. An LPN is not allowed to note orders but they can do the 24 hour chart check.

[LouisVRN, RN]

At are hospital all orders must be noted by an RN, although this has lead to some confusion. I learned to note off an order only if everything from that order had been transcribed correctly into the computer while others feel as long as they've seen it they will note it. If I am entering orders I note them as I enter them and then tell or give the nurse the new orders.

[jmgrn65, RN]

Only an RN can sign off orders, and they are supposed to make sure they have been placed correctly by the Unit Clerk

[SHURN]

At out hospital, the RN must sign off the order. This is a verification that the order was put through the system correctly and that the RN is aware of it. Remember, orders can be transcribed incorrectly, so just because the RN see that the secretary signed it off, that does not mean it was correct. If an order is not carried out, the issue is followed all the was back to the RN that signed it off. We also do 12 hr and 24 chart checks to ensure the whole days orders are in correctly.

[JustEnuff2BDangerous, BSN, RN]

We charge our own pts on my floor (we don't have one single charge nurse for the floor), so each RN is responsible for noting the orders on his/her pt's chart. Typically our unit secretaries will put their initials on the order (saying they saw the order and faxed it to pharmacy/entered labs into the computer/called Drs for consults/etc), give one of the yellow carbon copies to the LPN (we still do paper charting), and then will put the chart in a predefined place until we note it.

By noting the order I, as the RN, am saying that I am aware of the order and everything necessary to fulfill that order has been done (i.e., if there was a med ordered, it is on the profile in the right dose, time, and route; if there was a lab ordered, it is in the computer for the right date and time; if there was an order to D/C a Foley or an IV it either has been done or I am ensuring it will be done).

[CopperEmerald]

Thanks for the replies everyone. I appreciate it!

[CS1234]

Im interested in this topic also. Im finding out that many nurses at my institution "take off" orders for different reasons. They are - "I saw the neworder", "I saw and initiated the order if appropriate", "the order iscompleted", and "I have professionally evaluated this order". My institution also has electronic medical records (EMR), no paper charting unless we are on contingency. So, because of this, my institution is trying to define "taking off orders". Regardless, thank you for the continued discussion. If you have your hospital's policy, I'd greatly appreciate seeing it to develop one for my institution.

Thanks all!