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Doctors order sheet

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medical documentation

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Doctors order sheet

  1. 1. Dr. M. Yusuf
  2. 2.  To establish guidelines and the responsibilities for various disciplines who depend on the medical record as the primary tool for communicating information to patient care.  To provide standards for uniform documentation practice by all physicians.  To ensure competent records toward fulfillment of medico-legal responsibility of physicians.
  3. 3. Patient Care Orders are: the physician prescriptions, or authorization for the diagnostic or treatment service to a patient.
  4. 4.  Most Important Communication piece Culmination of all skills (Assessment, Analysis, Plan)  Initiates all care  Historical record; Sequence of events  Communication to all caregivers  Communication to lawyers
  5. 5.  Entries may be made into the medical record by: Physicians, Nurses, Pharmacists, RT, Dietician, Care Coordinator, Special Ed Teachers, Dentists, Midwives, Paramedic, Social Worker, Recreation Specialist, Radiology tech.  Your entries communicate to all of these professionals
  6. 6.  The following health care professionals may accept and document patient care orders:- 1. Professional nurses/ midwives, 2. Dieticians, 3. RT, 4. Pharmacist, 5. Physical/occupational/speech therapist, 6. Radiology technicians, 7. Dental therapist, 8. Orthopedic technicians, 9. Designated CT and MRI technicians.
  7. 7.  If the individual authorized to accept patient care orders believes that any orders fail outside acceptable standards of patient care, or is otherwise inappropriate, unreasonable, that person must refuse to execute it.  They must promptly inform the physician why they refuse the order.  If the order remains unchanged, the individual should notify their supervisors, and a physician at the next higher level.
  8. 8.  physicians order are documented in consistent location with in medical record  Physicians orders include medication and non- medication orders.  Must be written and signed by the physicians before they can be executed, except in case of V/O and T/O.  Shall be precise e.g.; PRN orders shall estate the indication for administration of the drug.
  9. 9.  Only forms approved by the Medical Records Committee shall be used in the record  All entries must be legible with author clearly labeled, with date(date-month-year sequence) and time(24-hours clock system).  Every page shall contain patient’s name and medical record number.  Who is responsible for this? YOU, and anyone writing on the page.
  10. 10.  Continuous; lines/space, if skipped, should be marked through.  Made in black or dark blue ink.  Only approved abbreviations and symbols may be used.
  11. 11. 1) Timely 2) Clear 3) Concise 4) Organized 5) Legible Re-evaluate as frequently as required for patient condition changes
  12. 12.  A physician shall not change the orders or plan of management of another physician, unless:- 1. Specifically requested or authorized by the attending physician. 2. The chief of service deems it necessary, urgent and in the patients best interest to do so.
  13. 13.  When an error occurs, a line should be drawn through it and the word error written on the line next to it. This is followed by name, title, date and time.  Then, re-write proper information.  No correction fluid is to be used.  Don't use eraser
  14. 14.  Use of identification stamp is encouraged.  When stamp is used, a signature must still be present above the stamp.
  15. 15.  Diagnostic and therapeutic orders.  Admitting And Preoperative Orders.  Postoperative Orders.  Verbal Orders.  Telephone Orders.  Routine orders.  Discharge Orders.
  16. 16.  The procedure: 1. Listen to the order, 2. Repeat the patient’s name, file number, room number, diagnosis and complete order back to the physician to ensure accuracy. 3. Record the order, 4. Record the date and time,  Sign your name and badge number, before the end of the next calendar day after the order was given.
  17. 17.  V/O are appropriate in the following situations:- 1. Emergency. 2. If practitioner placing the order is physically unavailable and order has urgency. 3. If physician is performing a procedure.  Must be signed, dated and timed within 48 hours (except Med orders and restraint orders which are 24)
  18. 18.  Cannot be used for: 1) Chemo, 2) DNR/Code Status; 3) Post OP, 4) PCA; 5) Hyper- alimentation; 6) Withdrawal of life support; 7) Heparin; 8) Initial parenteral orders of narcotics
  19. 19.  Admit to : Ward, ICU, or preoperative room.  Diagnosis: Primary Diagnosis, Other Diagnoses  Indication and Intended operation.  Condition: Stable  Nursing Vital Signs:  Frequency of vital signs;  Input and output recording;  Neurological or vascular checks.
  20. 20.  Notify physician if blood pressure <90/60, >160/110; pulse >110; pulse <60; temperature >38.5; urine output <35 cc/h for >2 hours; respiratory rate >30.  Activity level (precautions, bed rest, elevation of bed, weight bearing restrictions, rotation bed, bathroom privileges )  Allergies: No known allergies  Diet: NPO
  21. 21.  Medications:  Antibiotics to be initiated immediately preoperatively; Additional dose during operation and 1 dose of antibiotic postoperatively.  Must be on Doctors order form or other approved form (Heparin, Lovenox and Protonix)  Include all Drug; Strength; Route; Frequency  All strengths and volume in metric system
  22. 22.  Parameters required for PRN (fever, pain)  only one range of dose per statement,( eg; Morphine xx - xx every 4 hours for pain)  All medication orders must be individually reordered following surgery. “Resume” orders are not acceptable  “Resume Home Meds” cannot be used.  Any ambiguous or illegible order will be required to be re-written prior to filling the medication
  23. 23.  All home medications brought into the hospital to be utilized by inpatients will be verified first by pharmacy as the proper medication prior to administration.
  24. 24.  Labs and Special X-Rays:  Electrolytes, BUN, creatinine, INR/PTT, CBC, platelet count, UA, ABG, pulmonary function tests.  Chest x-ray (if >35 yrs old),  ECG (if older then 35 yrs old or if cardiovascular disease).  Type and cross for an appropriate number of units of blood.
  25. 25.  Transfer: From recovery room to surgical ward when stable.  Vital Signs: q4h, I&O q4h x 24h.  Activity: Bed rest; ambulate in 6-8 hours if appropriate. Incentive spirometer q1h while awake.  IV Fluids: IV D5 LR or D5 1/2 NS at 125 cc/h
  26. 26.  Diet: NPO x 8h then sips of water. Advance from clear liquids to regular diet as tolerated.  Medications: 1. Cefazolin 1 gm IV q8h x 3 doses; 2. Meperidine 50 mg IV/IM q3-4h prn pain  Laboratory Evaluation: CBC, Chest x-ray in AM if indicated.
  27. 27.  Post-operative, pre-admission, pre- procedures orders are valid for 30 days in the event the surgery, admission, procedure is delayed, and as long as patient’s conditions unchanged.
  28. 28.  Are preprinted sets of instructions for the patient care which can be initiated by a nurse in the absence of physician order.  Amendment may be made to the pre-printed orders by a physician in writing, verbally or over the telephone.  Must be signed by the attending physician within the next calendar day.
  29. 29. 1) Its not so easy. Slow down. Re-read what you wrote. Ask for help. 2) Watch unapproved abbreviations 3) 5 Basics (Pt, drug, dose, route, time) 4) PRN need a rationale 5) Don’t use two ranges in same order (20-40 mg q 4-6 hours) 6) Legibility

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