Processing Physicians Orders

Questions and Answers

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?

The physician

The nurse

The unit clerk (correct)

The pharmacist

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?

The date it was written, the order itself, the physician's signature, and the time it was written. Signup and view all the answers

What do medication orders cover?

All medications that may be prescribed for patients through different routes. Signup and view all the answers

What do dietary orders include?

All nutritional requirements of the patients. Signup and view all the answers

What is covered under diagnostic orders?

All lab blood and body fluid tests and tests from departments like medical imaging. Signup and view all the answers

What do activity orders dictate?

The various activity levels for patients. Signup and view all the answers

What do treatment orders encompass?

Various treatments a patient receives while in the hospital. Signup and view all the answers

What are miscellaneous orders?

Orders covering a variety of different situations regarding patient care. Signup and view all the answers

What are standing orders?

Orders that remain in effect until discontinued or changed. Signup and view all the answers

What are standing PRN orders?

Orders that are carried out only as necessary Signup and view all the answers

What characterizes one-time or specific time-limited orders?

They are written for procedures required either once or for a short duration. Signup and view all the answers

What is the definition of stat orders?

Orders that are to be processed first and carried out immediately. Signup and view all the answers

How does a physician flag the chart?

By marking it with indicators like 'Dr's order, Stat.' Signup and view all the answers

Who records on the physician's order sheet?

The physician, nurse, and unit clerk. Signup and view all the answers

What should you do if you make an error on the physician's orders sheet?

Draw one line through the error, write 'er,' initial it, and rewrite the correct information. Signup and view all the answers

What does the abbreviation 'IV' stand for?

Intravenous. Signup and view all the answers

What does 'hs' mean in medical terms?

Hour of sleep. Signup and view all the answers

What is the meaning of 'PO'?

Per os, or by mouth. Signup and view all the answers

What does 'RMO' stand for?

Requisition made out. Signup and view all the answers

What is indicated by 'u/a'?

Urinalysis. Signup and view all the answers

What should you do first when processing physician's orders?

Process STAT/NOW orders first. Signup and view all the answers

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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Description

This quiz covers the essential aspects of processing physician's orders within a hospital setting. It highlights the responsibilities of healthcare professionals in documenting and communicating patient care. Use this flashcard set to reinforce your understanding of physician's orders and their significance in medical practices.