Podcast
Questions and Answers
What is the primary purpose of Physician's Orders?
What is the primary purpose of Physician's Orders?
- To communicate the medical care the patient will receive (correct)
- To document the tests performed
- To track patient meals
- To record patient discharge plans
Who is responsible for processing the orders after they are written?
Who is responsible for processing the orders after they are written?
- The physician
- The nurse
- The unit clerk (correct)
- The pharmacist
What does a patient's nurse check to ensure?
What does a patient's nurse check to ensure?
That all orders are communicated and transferred to the patient's kardex.
What are the components of a Physician's Order?
What are the components of a Physician's Order?
What do medication orders cover?
What do medication orders cover?
What do dietary orders include?
What do dietary orders include?
What is covered under diagnostic orders?
What is covered under diagnostic orders?
What do activity orders dictate?
What do activity orders dictate?
What do treatment orders encompass?
What do treatment orders encompass?
What are miscellaneous orders?
What are miscellaneous orders?
What are standing orders?
What are standing orders?
What are standing PRN orders?
What are standing PRN orders?
What characterizes one-time or specific time-limited orders?
What characterizes one-time or specific time-limited orders?
What is the definition of stat orders?
What is the definition of stat orders?
How does a physician flag the chart?
How does a physician flag the chart?
Who records on the physician's order sheet?
Who records on the physician's order sheet?
What should you do if you make an error on the physician's orders sheet?
What should you do if you make an error on the physician's orders sheet?
What does the abbreviation 'IV' stand for?
What does the abbreviation 'IV' stand for?
What does 'hs' mean in medical terms?
What does 'hs' mean in medical terms?
What is the meaning of 'PO'?
What is the meaning of 'PO'?
What does 'RMO' stand for?
What does 'RMO' stand for?
What is indicated by 'u/a'?
What is indicated by 'u/a'?
What should you do first when processing physician's orders?
What should you do first when processing physician's orders?
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Study Notes
Physician's Orders Overview
- The resident physician examines the patient and writes admission orders for their care during the hospital stay.
- Physician's orders communicate the medical care plan, including tests, medications, and treatments.
Duties of Healthcare Staff
- Unit Clerk: Responsible for processing physicians' orders and notifying relevant departments about procedures.
- Nurse: Ensures all orders are communicated and recorded in the patient's Kardex for ongoing care reference.
Components of a Physician's Order
- Date the order was written.
- The order itself, which may involve multiple instructions.
- Physician's signature; some hospitals require a billing number alongside.
- Time of order creation is often omitted.
Classifications of Physician's Orders
- Medication Orders: Include all prescribed medications, specifying administration routes (e.g., orally, intravenously).
- Dietary Orders: Address nutritional needs, including restrictions and tube feeding.
- Diagnostic Orders: Comprise lab tests and imaging studies.
- Activity Orders: Define patient activity levels, such as bed rest or ambulation.
- Treatment Orders: Detail treatments like wound care or therapy sessions.
- Miscellaneous Orders: Cover various patient care situations, including transfers and day passes.
Categories by Duration
- Standing Orders: Remain effective until altered or discontinued; may have specific expiration dates for certain medications.
- Standing PRN Orders: To be carried out as needed, effective until changes are made.
- One-time or Specific Time-limited Orders: For procedures needed once or for a short period.
- Stat Orders: Require immediate action with no specified duration; prioritized for processing.
Identifying and Recording Orders
- Physicians flag charts with indicators for new orders and specific actions required.
- Various staff (physicians, nurses, unit clerks) are responsible for different documentation types.
Recording Guidelines
- Errors on the physician's orders sheet must be corrected properly with "er" notation and initials.
- Always verify and double-check each entry to avoid transferring errors to other documents.
Transcription Symbols
- Common transcription symbols include:
- Faxed @ time
- MAR for Medication Administration Record
- OE stands for Order Entered (Electronic)
Guidelines for Processing
- Review previous orders thoroughly to avoid omissions.
- Prioritize STAT orders as they may impact patient safety.
- Maintain accuracy by cross-checking against the physician's orders at each stage of record processing.
- Addressograph labels for consistency and effective time management.
- Ensure to flag the chart for nurse awareness and avoid assuming order clarity; always confirm details.
Abbreviations
- IM: Intramuscular
- IV: Intravenous
- PA: Posterior Anterior
- PO: Per os (by mouth)
- q: Every
- RMO: Requisition made out
- RVS: Routine Vital Signs
- u/a: Urinalysis
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