Outpatient Physician Telephone Orders Form - PDF

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					                                               UTMDACC INSTITUTIONAL POLICY # CLN0649



                                               PHYSICIAN ORDER POLICY - INPATIENT &
                                               OUTPATIENT


PURPOSE

To provide guidelines for receiving and implementing the physician's orders in such a manner as to
ensure that the patient receives treatments, medications, tests, and procedures as ordered.


POLICY STATEMENT

   It is the policy of the University of Texas M. D. Anderson Cancer Center that orders by physicians or
    designees will be managed consistently with this policy, the Division of Pharmacy “Safety Standards
    for Medication Use”, and the policies of the Executive Committee for the Medical Staff.

   Orders may be received from the physicians with clinical privileges at the institution or from properly
    authorized house staff. Orders written by medical students are accepted only when counter-signed by
    a licensed physician.

   Orders may be given by a midlevel provider/practitioner within that provider's licensure and scope of
    practice. Midlevel practitioners include advanced practice nurses, (nurse practitioners and clinical
    nurse specialists), physician's assistants, and pharmacists with DTM recognition. (Refer to Policy
    and Guidelines for Verbal and Telephone Orders From Physicians and Mid-Level Providers
    (UTMDACC Institutional Policy # CLN0613)).

   Some orders require the signature of the attending physician or require that the order be read back to
    the prescriber. (Refer to Chemotherapy/Biotherapy Policy (UTMDACC Institutional Policy #
    CLN0512)).

   Verbal orders received during a cardiopulmonary arrest situation and recorded on the
    Cardiopulmonary Resuscitation Record need not be documented on the Physician's Orders form.
    The physician will sign the CPR Record to verify these orders.

   Comfort Care Order Sets are signed and dated by a physician and/or designee prior to the nurse
    activating and pharmacy processing the orders. They may be institutional or service specific.

   Orders designated STAT shall be transcribed and implemented immediately. Those orders
    designated "now" or "rush" shall be transcribed and implemented within one hour. Routine orders
    should be transcribed and implemented within 4 hours.

   Medication "hold" orders without a time or action qualifier are to be regarded as an order to
    discontinue the medication.

   The nurse who verifies the physician's order is accountable for the content of the order adhering to
    policies and standards that govern nursing practice.


                                                                                                                    Page 1 of 8

This document is the property of The University of Texas M. D. Anderson Cancer Center and, with few exceptions, may not be used,
distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0649


   Inpatient Service Coordinators are responsible for transcription of inpatient physician orders. Stat
    and now/rush orders must be immediately reported to R.N./L.V.N. caring for patient.

   Orders will be rewritten in the following instances:

             When a patient is transferred from one service to another.

             Upon admission or discharge from intensive care areas.

             After use of general anesthesia.

   Automatic cancellations of all medication orders occur according to the Division of Pharmacy “Safety
    Standards for Medication Use”.


OUTPATIENT

   The "Outpatient Physician's Orders" form will be utilized for:

             Medication (any route) administered by MDACC staff in the clinic or ATC

             Therapeutic orders to be performed in a clinic (bladder irrigation, seroma drainage, etc.)

   Outpatient medication orders are discontinued by an intervening hospital admission and should be
    rewritten upon discharge.

   Outpatient medication orders to be continued through an admission must be written on an inpatient
    physician order form and rewritten as outpatient orders upon discharge.

   Tests or services ordered on the CSR for diagnostic imaging studies, physical therapy requests, etc.
    may be enacted on the instruction of the supervising or responsible physician prior to counter-
    signature, if the requisition includes the name and identification number of the physician.

   The PSC will not take off any orders that have not been dispositioned by an RN/LVN.


SCOPE

RN, LVN: Accepting, transcribing, verifying orders.

RN, LVN, Inpatient Service coordinator (ISC), Patient Services Coordinator (PSC): Transcribing
orders.


DEFINITIONS

Comfort Care Orders: Pre-printed PRN order sets intended to manage clinical symptoms during an
inpatient stay.

Initiate: Signing of comfort care order sets by a physician/designee.

Activate: Signing of comfort care orders by an RN when a clinical symptom requiring treatment is
identified.

                                                                                                                    Page 2 of 8

This document is the property of The University of Texas M. D. Anderson Cancer Center and, with few exceptions, may not be used,
distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0649



PROCEDURE

1.0   Transcription

      1.1    Read the order to ascertain if immediate action is required. ISC will immediately notify the
             nurse of stat or now/rush orders and fax the order to the Pharmacy.

      1.2    Place initials (in red) in the far right column adjacent to each

      1.3    line of the order on the Physician's Orders form as each portion of the order is transcribed.

      1.4    For a STAT/now order, indicate (in red) the time the specific order was transcribed and initials
             of individual transcribing the order.

      1.5    After an order or group of orders have been transcribed, the ISC will document the time, date,
             first initial, surname and title (in red) in the right hand corner directly below MD signature.

      1.6    For all consults, the ISC will contact the appropriate physician's or service office. Document
             contact in medical record, Nursing Kardex, and ISC Kardex

      1.7    For all scans, the ISC will schedule on-line or fax to appropriate department the request. The
             ISC will obtain schedule from the computer and document schedule on Nursing Kardex and
             ISC kardex.

      1.8    For cardiopulmonary requests, the ISC will contact department for scheduling. ISC will obtain
             schedule from computer and then document schedule on Nursing Kardex and ISC kardex.

      1.9    For EEG, the ISC will contact the department to schedule and document the schedule on
             Nursing Kardex and ISC kardex. EEG requisition will be left on chart to accompany patient to
             the test.

      1.10 For EKG, the ISC will call the department to schedule. Maintain EKG request on the unit.
           Document schedule on Nursing Kardex and ISC Kardex.

      1.11 For all treatments the ISC will document on Nursing Kardex in the appropriate section. Initiate
           appropriate requisitions for necessary supplies or equipment to implement treatments.

      1.12 For nutrition orders, the ISC will document type and date on Nursing Kardex and ISC Kardex.
           ISC will enter diet orders into the computer.

      1.13 For all equipment the ISC will complete appropriate requisition and send to appropriate
           department. Consult with nurse if necessary.

      1.14 For all specimens (non-blood), the ISC complete appropriate laboratory requisition (via
           computer or paper requisition as indicated) and document on Nursing Kardex under
           "Specimens".

      1.15 When a non-medication order is discontinued (such as a lab test, etc.), the ISC will notify the
           appropriate department(s) of discontinuance of services requested. Erase appropriate
           information on Nursing Kardex and ISC Kardex. Delete from the computer, if appropriate.

      1.16 If a request for a test has not been properly completed, the ISC will notify the nurse, and if
           directed to do so, the ordering physician.

                                                                                                                    Page 3 of 8

This document is the property of The University of Texas M. D. Anderson Cancer Center and, with few exceptions, may not be used,
distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0649


2.0   Medication Orders

      2.1    The ISC will transcribe the medication order to the appropriate Medication Administration
             Record where indicated.

      2.2    The Medication Administration Record shall reflect drug, dosage, route, frequency,
             administration times, date of order, and renewal/stop date, if indicated.

      2.3    Each different route of the same medication (i.e., Tylenol 650 mg. po or suppository) must be
             transcribed in separate boxes.

      2.4    When two or more medications are ordered to be given simultaneously, each separate
             medication will be written in a separate box on the MAR.

      2.5    An error in the initial transcription of a medication order to the administration record is
             indicated by writing "Error in Entry" across the box containing the incorrect information. Initials
             of individual documenting should be included in the box and identified at the bottom of the
             record. The entire box (drug column and date column) will be marked out or crossed out with a
             yellow felt-tip pen. Another box shall be used to write the correct information

      2.6    Information documented in the boxes on the Medication Administration Record must not be
             altered after the initial transcription (i.e., changing route, changing additives, etc.).

      2.7    On the appropriate Medication Administration Record, indicate the renewal, change and/or
             discontinuing of a medication by writing "DISC" in the respective date column for the
             discontinued medication. Include the date, time, and initials of the individual transcribing the
             order. Identify initials at bottom of record. The drug/date columns should be marked/crossed
             out with a yellow felt-tip pen. The medication Kardex, if used, should reflect renewals and
             changes. Discontinued orders should be erased.


3.0   Comfort Care Orders

      3.1    Nursing

             A.     Validate that Comfort Care Orders have been initiated

             B.     When a clinical symptom requiring treatment is identified, activate Comfort Care Orders
                    by timing, dating and signing the right hand side of the order set

             C.     Transcribe the order, if not done by ISC

      3.2    ISC

             A.     Fax order set to pharmacy upon initiation and activation

             B.     Transcribe the order upon activation

      3.3    Pharmacy

             A.     A dated written message will appear on the MAR as a reminder that Comfort Care
                    orders have been initiated

             B.     Enter medications from the order set into the pharmacy system for dispensing upon
                    receipt of activated order set
                                                                                                                    Page 4 of 8

This document is the property of The University of Texas M. D. Anderson Cancer Center and, with few exceptions, may not be used,
distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0649


4.0   Physician Outpatient Orders Procedures

      4.1    The nurse reads the order to ascertain if immediate action is required and/or patient teaching
             needed.

      4.2    The center nurse will:

             A.     Place a legal signature in the space provided on the CSR, using first initial, surname and
                    title upon completion of disposition of the order.

             B.     Perform and document any applicable patient teaching

             C.     Check any orders going to the ATC for accuracy and completeness, including patient's
                    height, weight and allergies

             D.     Route patient for scheduling per center procedure

      4.3    The PSC will:

             A.     Schedule all appointments as indicated on the CSR according to the procedure for
                    scheduling appointments.

             B.     If orders involve appointments in the ATC, calculate length of time required for therapy,
                    using standard administration time from pharmacy.

             C.     Call/fax the ATC to schedule appointment

             D.     Note time of ATC appointment on "Outpatient Physician Orders" form next to order,
                    along with area in which patient is to receive therapy.

             E.     If no appointment is available at requested time, notify center nurse. "Unscheduled
                    appointments will be arranged between ATC Nurse Manager/Assistant Nurse
                    Manager/Charge Nurse and ordering physician/mid-level provider/center RN.

             F.     Fax copy of the "Outpatient Physician Orders" form to the pharmacy (for any medication
                    order) as soon as possible, and to the ATC if indicated. The original order form will be
                    sent for scanning into the electronic medical record.

             G.     Give patient his/her appointment time in the ATC as per clinic standard.

      4.4    The ATC nurse will indicate verification of the order as previously described in this policy.


5.0   Verification of Orders

      5.1    After each specific set of orders has been transcribed, the nurse will indicate verification of the
             order by bracketing the entire order(s) (in red) and include the time, date, first initial, surname
             and title below that of the ISC signature. Medical record will be flagged black to indicate
             orders have been verified.

      5.2    Each set of signed physicians orders must contain a nurses signature verifying that set of
             orders.



                                                                                                                    Page 5 of 8

This document is the property of The University of Texas M. D. Anderson Cancer Center and, with few exceptions, may not be used,
distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0649


      5.3    Verification of a medication order, any route, will be indicated by the nurse placing initials in
             the lower right corner of the appropriate space on the Medication Administration Record.
             Initials must be identified at the bottom of the record.

      5.4    The nurse may document nursing actions (i.e., record apical pulse,blood pressure, etc.
             administer with milk, etc.) and special instructions/documentation (i.e., platelet count 90
             minutes post-transfusion, number doses of drug to be administered) if appropriate on the
             Medication Administration Records and/or the Medication Kardex.

      5.5    The unit coordinator will maintain an adequate number of Inpatient Physician's Orders forms
             in the patient's medical record.




                                                                                                                    Page 6 of 8

This document is the property of The University of Texas M. D. Anderson Cancer Center and, with few exceptions, may not be used,
distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0649




REFERENCES
None.




                                                                                                                    Page 7 of 8

This document is the property of The University of Texas M. D. Anderson Cancer Center and, with few exceptions, may not be used,
distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                                 UTMDACC INSTITUTIONAL POLICY # CLN0649


Approved With Revisions Date: 08/01/2005
Approved Without Revisions Date:
Implementation Date: 08/01/2005


Governors
Summers,Barbara L -VP, Nursing Prac &Chf Nrsg Off


Stewards
Burns,Latasha R -Assoc Dir, Nrsg Accreditation


Content Experts
Bowman,Virginia B -Advanced Practice Nurse
Burns,Latasha R -Assoc Dir, Nrsg Accreditation




                                                                                                                             Page 8 of 8

      This document is the property of The University of Texas M. D. Anderson Cancer Center and, with few exceptions, may not be used,
      distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.

				
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