Writing Clarification Orders

[TrixieKat]

Hi All,

Sorry this is kind of long:yawn:.

Need some clarification. Here is the situation. I work in a Long Term Care facility. There is a nurse manager who writes a lot of "clarification orders" as the first order written (no previous order to clarify). Example:

3/23/09 Clarification Order: Cleanse skin tear to left wrist with wound cleanser, apply TAO and Band-Aid QD & PRN until healed. (Then she signs it).

There is no previous order regarding a skin tear on the left wrist. When I asked her why she wrote it as a clarification order, she stated that there was documentation about the skin tear on 3/22/09 (the incident report was done on 3/22, no other documentation). She stated, "I was taught in nursing school that if there was documentation but no order written at that time to write an order as a clarification order to cover your a$$." I have never heard of this. Our Administrator and Risk Manager have never heard of this. Our Administrator and Risk Manager are also Legal Nurse Consultants and have told her not to write "clarification orders" unless she is actually clarifying an actual written order. The nurse manager did not come to work the next day. The day after that she informed me that she had spent the previous day on the phone with "a nursing organization", which she would not clarify who, and that they told her that the way she is writing clarification orders is correct. She also said she had an email from them proving this and she was going to email it to our Risk Manager. I asked her to email it to me, but she wouldn't. She said she had to do some tweeking to it. Sounds fishy to me.

I also see clarification orders for treatment changes. Example. An order for corn cushion to corn on left middle toe written in January. In March: "Clarification Order: Corn cushion to corn on left middle toe and right pinky toe." I told them that this is NOT a clarification order. This is two separate areas and there should be a new order. I was told I was wrong (by the same nurse manager).

By the way: I'm the Care Plan Coordinator - and things like this are going into the care plans. And who do you think will get cited by surveyors - me! So I try to keep things "clarified.":chuckle

My question is: When do you write clarification orders? I thought it was to clarify if the first order was written wrong, such as wrong dose (was written 25mg and should have been 0.25mg, etc.), wrong route (should be PEG instead PO), etc.

[TrixieKat]

Hi Again,

I'm new to this, and was wondering why my post is not showing up in the New Posts area. I thought that if I posted a Reply, it would show up.

[Nascar nurse, ASN, RN]

I would agree with you on clarification orders!

[caliotter3]

I have also seen where clarification orders are written the way you describe, both ways. When there is no original order to begin with, it is done that way because there "may" have been an order that has been lost in the shuffle and this is a way to deal with getting an order in place.

[TrixieKat]

I audit every chart once a week and see every order written, so there are no previous orders for these clarification orders. One clarification order was written and the nurse's note that went along with the order stated, "New order written." Asked her to explain that one, but didn't get an explanation. I just put what I find on a report and turn it into the Administrator and DON and let them handle it from there.

[CoffeeRTC, BSN, RN]

A clarification is to clear up a previous order. What she is doing is making an origional order. You are right.

Most often our clarification orders are because docs write 1-2 tabs ever 4-6 hrs...etc.

[Alibaba]

U know, I have seen lots of these 'clarification orders' especially on treatments. They always appear when the chart is audited or is gone through by MDS. I always take it as a way of the management making sure their ducks are in a row. After all, you don't want state coming into the facility and asking where the order for that treatment is. NO order anywhere, means you are practicing medicine without a license.

At most places I have worked, there are standing orders for things like skin tears and raw bottoms. When you notice these things you are supposed to write a T.O, then leave a msg for the doc that you initiated the tx. The prob is that many times, we just initiate the tx and put it on the tx book, but never write a T.O for it. When a review is done, there is no order written. So, technically, you can write a 'clarification' later based on the standing order. At least that's how I understand it.

Interesting this came up now coz we are expecting state any day now and we have had a huge amount of 'clarification' orders from everywhere. Treatment nurses, dietary, therapy...everyone is trying to CYA.

[Havin' A Party!, ASN, RN]

If a treatment has been administered on an ongoing basis, but no written order can be located, a clarification may be in order (pun intended).

But when writing an ordinary original order, it makes no sense to me to preface / label it as a "clarification order."

[CapeCodMermaid, RN]

In order for there to be a clarification, there must be an original order which needs to be clarified....I've been a nurse for more than 25 years and have never seen it done any other way. I sure would like to know what 'nursing organization' told that nurse her way was correct!

[caliotter3]

I think that nursing organization is a figment of her imagination. Although, I've seen clarification orders written on nonexistent original orders, I've always known that this was another roundabout way of doing things. Whenever I would ask questions about things like this, I would get jumped upon by those who had been around longer than me, so that told me the rules were being bent.

[TrixieKat]

Our risk manager was in our building today. She's only there 1 day a week. I asked her if she had gotten an email about the "clarification orders." She said no and didn't know what I was talking about. So I filled her in. She thinks that there is no email from whatever organization, but if she does get one, she's going to forward it to me. Nothing has been said about writing clarification orders since the nurse manager spoke to me about the email.

I won't be auditing the charts until Thursday (and it may have to wait until next week--Easter vacation, going out of town). And then I'll know if there are any more "clarification orders."

Our wound care nurse is kind of a new nurse. She was a med nurse for about a year and then became our wound care nurse. (No one else wanted it.) This nurse manager has taught her to write her orders as clarification orders. When Adm & DON talked to her, she said that was what she was told to do it. Now she knows the correct way. I also told them that clarification orders can't be counted on the MDS for reimbursement and we could lose a lot of money if it were during a resident's assessment period. That really opened the Adm ears. We like money -- we like raises .

In my facility I'm called the computer wiz. Our IT from corporate calls me for help at times. I can do almost anything on a computer. I fix them (if it's something simple like getting a printer to network), I make charts, graphs, etc., I can find out almost any information about anything that someone wants to know - I love the net, but I couldn't find any site or organization on the net with any information, guidelines, or regulations about clarification orders, except when to call the MD about clarifying his order because you can't read it. This nurse manager calls me to restart her computer for her, so how could she find this info on the net when I couldn't?

[noc4senuf]

Never heard of writing clarification orders the way you describe. My nurses would get some re-education in a hurry if I ever saw it that way.