inpatient versus observation orders

I know this is a little off from the normal conversation of CDI, but I have a question for anyone using computerized physician order entry. When a physician orders inpatient or observation through a computer order entry system, and he/she chose the wrong status, how do you address or change this? In a hand written world, the case managers, nurses, or physicians would change the order by hand writing it in the chart. However, if there is no "physical" chart because it is in the computer, how does the order get to be reclarified to the correct status? I hope this makes sense.

Comments

  • We have dealt with this issue by granting nurses the ability to clarify
    the order. One of our Case Managers will contact the doctor and report the
    order written and the level of service that should be ordered. If the
    physician agrees, we enter a new order. Our IT department has a field for
    clarifications, and from what time and date the order was intended to be
    from. The nurse will typically enter the date and time of admission or
    transfer from PACU. Other than that and issues of pain, puke, poop (3P's
    for our staff nurses)... we don't write orders for our docs. In the event
    of an emergency our rapid response and code blue order sets are
    implemented by the nurse.

    Bill Freeman, RN, BSN
    Supervisor of CDMP
  • edited May 2016
    Our case managers currently review all pt statuses as concurrently as possible. It depends on the payer and when the error is found as to how it gets changed. Typically we enter the status order with the a date a time as to when it is to be in effect and comment in an open area included in the order if necessary. With the computer order, the orders are not really vague so "clarification" isn’t always appropriate, but we do note "meets inpt criteria" or "meets obs criteria." Of course with medicare patients we do not back date inpt admit times even if inpt was appropriate rather then obs. We just change the status to inpt as of that date and time if they still are meeting criteria. We have had a lot of issues with this.


  • edited May 2016
    Thank you for your responses. What happens with orders that are given at 2:00 am or does the physician enter those orders remotely? I am not thinking of a admit order but a medication or xray that is ordered in the middle of the night?

    Colleen Stukenberg MSN, RN, CMSRN, CCDS
    815-599-6820

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