verbal orders

adrienne.bakeradrienne.baker
in CDI Talk Archive
Does anyone take and write verbal orders from physicians in the medical record.

Example: verbal query to physician for (+) UA and to start Cipro then the CDS writes it as a order in the chart along with the query? We currently do not do this and our coders wanted to know if anyone else currently does this?

Comments

  • cbarnescbarnes
    edited May 2016
    We do not take or write orders from the physicians.


  • nbrunson84nbrunson84
    edited May 2016
    No - we do not write orders. We are strictly Coding/DRG/Documentation
    Improvement.

    We have an interesting mix so far - LPN, RN, RHIA.


    N. Brunson, RHIA
    Clinical Documentation Specialist
    Bay Medical Center


  • Unknown
    edited May 2016
    I do not take orders from physicians. Our physicians enter their own orders so if I discover something along those lines, he enters the med order himself.


  • robert.hodges2robert.hodges2
    edited May 2016
    Not me.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "To climb a steep hill requires a slow pace at first."  -William Shakespeare
     

  • epraczepracz
    edited May 2016
    we don't.

    Eileen Pracz, RN
    Clinical Documentation Specialist
    Oregon Health Science University
    503-418-4023
    fax 503-494-8439
    pracze@ohsu.edu




  • digardskdigardsk
    edited May 2016
    I very rarely take a physician order (vo or to) and write it in the medical record. Most commonly it is for labs - to support a condition, improvement in a condition, clarify conflicting or ambiguous results.

    Kim

    Kim Digardi, RN
    Clinical Documentation Specialist
    St. Helena Hospital
    10 Woodland Road
    St. Helena, CA 94574

    Phone: 707.967.5936
    Email: digardsk@ah.org


  • nbrunson84nbrunson84
    edited May 2016
    I think it depends on your CDI program. Some CDI Programs are a mix of Case Management/CDI and I could see orders being taken and written.

    In our facility we are separate from Case Management and Utilization Management.


    N. Brunson, RHIA
    Clinical Documentation Specialist
    Bay Medical Center


  • digardskdigardsk
    edited May 2016
    I am a registered nurse employeed by the hospital and don't see it as an in or out of scope issue. It is not delineated in our job description, and I see it as similar to the occasional order written by CM.

    Kim

    Kim Digardi, RN
    Clinical Documentation Specialist
    St. Helena Hospital
    10 Woodland Road
    St. Helena, CA 94574

    Phone: 707.967.5936
    Email: digardsk@ah.org


  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    We are strictly CDS and we do not take verbal orders. Our case managers do not take verbal orders. We have a policy at our facility re: verbal orders and nursing "should" only take verbals under very limited circumstances.


  • digardskdigardsk
    edited May 2016
    This is true re "verbal orders", and I think the term is still used loosely and they are to be used only for "emergencies". I should restate my response to telephone orders...

    Kim Digardi, RN
    Clinical Documentation Specialist
    St. Helena Hospital
    10 Woodland Road
    St. Helena, CA 94574

    Phone: 707.967.5936
    Email: digardsk@ah.org


  • cbarnescbarnes
    edited May 2016
    At our hospital taking orders falls under the practice of clinical RN's. This could be included as part of their competency every year. Since we have a separate type of competency it was elected that we would not participate in all competencies, ie, med-surg, critical care, pediatrics, OB , (etc) practice. This keeps us specialized to our roles only.

    We do keep up w/ BCLS. One of us elects to keep her ACLS current but that is a personal choice not a requirement.


  • dogdog
    I don't write any verbal orders, although legally I can. I think it would be a conflict of interest to write a query and then write the response to it. At any rate, my supervisor discourages me from writing any verbal orders of any kind.

    Linda Renee Brown, RN, CCRN
    Clinical Documentation Specialist
    Arizona Heart Hospital
  • michelleclynemichelleclyne
    edited May 2016
    no


    Michelle Clyne, RN, BS
    Clinical Documentation Improvement Specialist
    Good Samaritan Hospital


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