THE CHAMBERSBURG

Subject: Article XXXVIII; Orders, Physician Original Date: 8/01/1993

Department: Medical Staff Revision Date(s): 06/18/2008 ; 11/25/2008; 01/17/2009; 08/2009; 09/29/2010; 07/20/2011 Area: Discipline:

Classification: Medical Staff Rules and Regulations Review Cycle: Annually

39.1 POLICY STATEMENT:

A. Authorized staff will administer medication or treatment only upon written and signed orders of a

practitioner acting within the scope of his or her license, except as provided in this article relating to

verbal orders.

B. The practitioner will:

a. Include the date and time that he or she wrote the order on all written orders, and

b. Print his or her name after the signature, or

c. Write his or her three-digit dictation number after the signature.

C. The receiving and validating of practitioners’ orders is the responsibility of the Registered Nurse. Unit

Secretaries and LPNs assist with the transcription of orders. By cosigning the unit secretary or LPN,

the RN is validating medication and IV orders only.

D. Nurses accept orders originating only from appropriately credentialed members of the Medical Staff or

other Allied Health providers whose practice the Medical Staff outlines in the Medical Staff Bylaws,

Rules, and Regulations. All nurses have access to a list of current Medical Staff and Allied Health

Professionals. A copy of the Medical Staff Bylaws, Rules, and Regulations, and privileges of

practitioners and allied health professionals practicing and/or admitting patients to the unit are located

in each unit. A complete master list is located in Medical Staff Services and Patient Services.

Staff must complete the documentation per policy and procedure.

39.2 PROCEDURE:

A. Purpose: To ensure accurate interpretation and transcription of orders.

B. Supplies and Equipment:

1. Chart.

2. Phone numbers of various departments for scheduling purposes C. Medication Order: The required elements of a medication order are:

1. The medication, including any dose designations (i.e., XL, XR, CR, CD).

2. Strength.

3. Route.

4. Frequency of administration.

a. If staff is to administer the medication “as needed,” and the medication has more than one

indication, the ordering provider must include the intended indication(s) with the order

(e.g., acetaminophen 1000mg by mouth every six hours for a fever greater than 101 oF.)

b. After noon, all daily medications, with the exception of antibiotics and anticoagulants,

would begin the next day unless the physician indicates: “first dose now.”

D. Verbal Orders : Authorized staff will accept verbal orders for medication or treatment only in emergency

or unusual situations (Department of Health Rule: 107.62), where the urgency of the medical

circumstances requires immediate medication or therapeutic treatment (Title 49 Professional and

Vocational Standards, Chapter 21). Only the following qualified personnel, with restrictions as noted,

who will transcribe the orders in the proper place in the , will take verbal orders:

1. A practitioner

2. A professional nurse

3. A licensed practical nurse, within policy of the Department of Nursing

4. A pharmacist who may transcribe verbal orders pertaining to drugs

5. A physical therapist who may transcribe verbal orders pertaining to treatments.

6. A who may transcribe verbal orders pertaining to respiratory therapy

treatments.

7. A paramedic practicing under regulations of the Department of Health.

The verbal order will include the date, time, and full signature of the person taking the order and the responsible

practitioner will countersign it within 24 hours. If the practitioner is not the attending practitioner, the

attending practitioner must authorize the practitioner, and the attending must be knowledgeable about the

patient’s condition. Failure to authenticate the orders may result in any of the corrective actions as outlined

in Article V of the Medical Staff Bylaws, Rules, and Regulations.

Note: Practitioners must write orders clearly, legibly, and completely. The nurse will not carry out orders that are

illegible or improperly written until the provider rewrites it or the nurse subsequently understands the order.

If at any time the RN or LPN taking the verbal order is unclear or questions an order, the nurse has the right to question the practitioner.

a. The LPN can take verbal and telephone orders for actions within their . The LPN

shall immediately transcribe verbal prescription or orders that he or she accepts in the appropriate place

on the Medical Record (State Board of Nursing 21.145).

b. At the time of a verbal order, if the practitioner does not ask about allergies, the nurse must

volunteer the allergy status to the practitioner.

1. Nurses write the verbal orders and read them back to the practitioner for verification of accuracy.

2. Documentation consists of the date, time of the verbal order, practitioner’s name, degree, and dictation

number, as well as the nurse’s signature who took the verbal order. The nurse documents all of this on the

physician’s order sheet. The nurse, respiratory therapist, or pharmacist utilizes the verbal order stamp to

ensure that he/she reviews the patient’s allergies with the provider and to indicate that a verbal order read

back occurred. (Example: MD name/name of RN taking order/date and time.)

3. Practitioners are to sign all verbal orders within twenty-four (24) hours.

E. Clarification of Orders :

a. If the RN questions the written order, contact the practitioner who wrote the order, as noted in the

Chain of Command policy and procedure. .

b. If a practitioner does not indicate the route of administration for a medication, the following

protocol should apply: If the medication is available only in oral form, the pharmacist will dispense

it as by mouth. If the medication is available in oral and injectable form, the pharmacist will call

the practitioner to seek clarification before dispensing.

c. Medication order – should there be a question as to drug, dosage or route of administration, the

nurse will not administer the drug but will:

1. Contact pharmacist to confirm usual dosage, route of administration, side effects, etc. of

medication.

2. Contact practitioner and discuss the medication order regarding the nurse’s concern:

Note: If the pharmacist contacts the practitioner and receives an order change, the pharmacist will write the order

on the chart, the pharmacist signs the order, followed by verbal order and the practitioner’s name.

3. If the practitioner insists the drug order remain unchanged, notify Nursing

Supervisor/Resource Nurse Manager who will then contact the practitioner, and refer to the Chain of

Command policy and procedure.

4. Practitioners are to write medication orders in accordance with the Formulary and policies and procedures pertaining to drug therapy as prepared by the and Therapeutics Committee and

approved by the Medical Executive Committee following Federal and State regulations.

5. The pharmacy will cancel all previous orders. The nurse or the unit secretary will place all

orders on hold when patients go to surgery.

F. Documentation : See 1.d and 3.b, 3.e, 4.b.

Notes: Any routine orders (i.e., Admission, PAT, preprocedure) that the practitioner sends by facsimile should be

included in/on physician order sheets as a permanent part of the medical record. The staff must affix patient

labels to each sheet. Do not recopy or discard the faxed sheet.