Open Forum

 View Only

  • 1.  Verbal Orders/Transcription of Orders

    Posted 05-23-2024 09:33

    Good Morning,

    I am working on a Verbal Order policy for my medical group to ensure that verbal orders are only accepted in emergency situations or when the provider is truly unable to enter in the EMR (ie- in a sterile procedure). However, transcription of orders from previous encounters is a bit of a gray area. For example, if a patient is to receive a B-12 injection monthly and there is a signed note from a previous encounter stating "Patient to receive B-12 x dose, subcutaneously, every month for 6 months," can a nurse or a CMA transcribe this to an active order and administer prior to the provider signing the transcribed order?

    If anyone has a policy, guidelines, or advice related to this, I would greatly appreciate it.



    ------------------------------
    Shannon Hager, BSN, RN[
    Director of Nursing and Quality
    Beebe Medical Group
    Ocean View DE
    (302)542-9289
    shager@beebehealthcare.org
    ------------------------------


  • 2.  RE: Verbal Orders/Transcription of Orders

    Posted 05-24-2024 06:48
    We rarely do verbal orders. If we know ahead of time that a patient is coming in for an injection such as a B 12 shot we have the provider place the order that day. That is best practice. If it is placed ahead of that day it will become "overdue " in EPIC. If for some reason the provider hasn't placed the order then a verbal order can be placed BUT the provider must co-sign it. So it makes more sense to have the provider place the order in the first place. Only the RN can place the verbal order in NYS. MA's can NOT place medication or vaccine verbal orders nor can they EVER administer meds/vaccines in NYS. 





    Original Message


  • 3.  RE: Verbal Orders/Transcription of Orders

    Posted 05-26-2024 19:08
    Hello,
    The one exception verbal orders are entered is during a medical emergency.
     For B-12 or other recurring injections (monthly or every 6 months etc.) our electronic medical record system is configured so that the provider can enter that order and it will be active on a nurse or provider visit. I believe the function is in the specific order set for the medication (testosterone, Deop, B -12, etc). The only glitch is that the patient may not come in exactly on the date it shows up in MAR. If it is reasonably early or late, an acceptable reason needs to be entered by the RN. 
    Lorraine



    Original Message


  • 4.  RE: Verbal Orders/Transcription of Orders

    Posted 05-24-2024 09:12

    It may be dependent on your state's laws regarding MA scope of practice. In Michigan, yes, if the components for the order is in the provider note, the MA may transcribe it and activate the order with a request for co-sign.

     

    This link is to a state by state MA scope outline by the attorney for AAMA - AAMA - State Scope of Practice Laws (aama-ntl.org). He has been very helpful in clarifying the MA scope for me.

     

    Regards,

    Leslie

    Leslie Hazle, MSN, RN, CPHQ (she/her)

    Director, Patient Safety & Clinical Risk

    McLaren Medical Group - Our Guiding Principle is to provide healthcare as we expect for our own family.

    G-3235 Beecher Rd.

    Flint, MI 48532

    PH: 810-342-1051

    Mobile: 703-980-0651

     

    "A bad system will defeat a good person every time."

    – W. Edwards Deming

     

    MMG_DWB Horizontal rgb

    This is a confidential professional/peer review and quality assurance document of the medical center. It is collected as patient safety work product  It is protected from disclosure pursuant to the provisions of MCL 333.20175, MCL 333.21513, MCL 333.21515, MCL 331.531, MCL 331.532, MCL 331.533, MCL 330.1143 and all other State and Federal law providing protection for facility professional review and/or peer review functions.  Unauthorized disclosure or duplication prohibited.

     

    McLaren confidentiality statement: "The information contained in this communication, including attachments, is confidential, may be privileged, and is intended only for the use of the named recipient(s). Unauthorized use, disclosure, forwarding or copying is strictly prohibited and may be unlawful. If you have received this communication in error, please notify me IMMEDIATELY at the phone number or pager listed above."



    Original Message


  • 5.  RE: Verbal Orders/Transcription of Orders

    Posted 05-24-2024 13:29
      |   view attached

    Hi Shannon,

    We also have an internal policy that you can only accept verbal orders in the case of an emergency. Attached is from NC DHSR regarding transcribing orders. I think this depends on your governing state bodies. 



    ------------------------------
    Torie Bonnet MSN RN NE-BC
    Clinical Nurse Edu Specialist-Ambulatory Care
    UNC Health
    Raleigh NC

    torie.bonnet@unchealth.unc.edu
    ------------------------------

    Attachment(s)

    pdf
    guidelinesforTranscribing.pdf   175 KB 1 version
    Original Message


  • 6.  RE: Verbal Orders/Transcription of Orders

    Posted 05-24-2024 14:02

    Our internal policy discourages use of verbal orders except in emergencies.

    We also list "things that are not orders"

    text messages

    secure chat

    TEAMS message

    Prior visit progress note

    are included in that list

    Transcribed orders must be written and signed with all details of a complete legal order and the document must be scanned into the EMR with the order. 



    ------------------------------
    Ray Snider DNP MSN RN NEA-BC
    Director Clinical Operations
    Emory Healthcare
    ------------------------------

    Original Message


  • 7.  RE: Verbal Orders/Transcription of Orders

    Posted 05-27-2024 09:41

    Great how one organization specifically also calls out 'things that are not orders'! 

    The North Carolina Board of Nursing has a position statement on the subject that leans heavily on agency-specific policies and procedures.

    https://www.ncbon.com/sites/default/files/documents/2024-03/ps-physician-orders-communication-and-implementation.pdf



    ------------------------------
    Leslie McDowell ANP-BC DNP RN
    QI Curriculum Developer
    Northwest AHEC/Wake Forest Univ Sch of Med
    Winston Salem NC
    (336)972-7852
    ANP-BC DNP RN
    ------------------------------

    Original Message


  • 8.  RE: Verbal Orders/Transcription of Orders

    Posted 05-28-2024 17:50

    We also only allow verbal orders in case of emergency.  For things to happen in the future, we have the ability to make it a "future order", which then gets pulled in to encounters until it is time for the order to happen.  We use this for the subsequent doses of some vaccines that are not routine, for the second and third doses of Bicillin for Syphilis treatment, etc.  It took a while to get the team used to this - the clinicians wanted the staff to abstract the order from the progress note when we first started using EHR, but it is finally institutionalized.

    I like to remind staff that they can't go through all of the checks and all of the rights of medication administration unless they have an order to compare it to.



    ------------------------------
    Lisa Duncan, DNP, MBA, RN, AMB-BC, CIC, NEA-BC
    VP, Regulatory and Compliance
    Family Health Centers of San Diego
    ------------------------------

    Original Message


Related Content