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