On completion of this chapter, you will be able to: 1. Define the terms in the vocabulary list. 2. Identify four methods that may be used by a doctor to provide orders for a hospitalized patient. 3. Name two criteria the health unit coordinator can use to recognize a new set of handwritten doctors’ orders that need transcription. 4. List the four categories of doctors’ orders, and explain the characteristics of each. 5. Describe the health unit coordinator’s role in processing doctors’ orders when computer physician order entry (CPOE) is used and in transcribing doctors’ orders when paper charts are used (handwritten or preprinted orders). 6. Identify five common areas found on the Kardex form and describe the purpose of Kardexing. 7. Describe the process of ordering diagnostic procedures, treatment, medication, or supplies via computer. 8. Name and describe the purpose of the symbols used in transcribing doctors’ orders, and describe the purpose and process of signing off on a set of doctor’s orders. 9. List in order the 10 steps of transcribing handwritten doctors’ orders. 10. Discuss why accuracy is important in the transcription procedure, the types of errors that may occur during the transcription procedure, and the methods of avoidance that may be used. A method used by the doctor to notify the nursing staff that a new set of orders has been written. A portable file that contains and organizes the Kardex forms for each patient on the nursing unit. One-Time or Short-Series Orders Doctors’ orders that are to be executed immediately then automatically discontinued. Hospitals across the nation are in the process of implementing electronic medical records (EMRs) and computer physician order entry (CPOE). When the EMR with CPOE is used, the doctor enters orders for a patient’s care and diagnostic studies directly into the computer on a physician’s order form and the appropriate departments automatically receive the computerized orders. The doctor records the date and time and electronically signs each entry. The doctor may write one order or a collection of orders; this is referred to as a set of doctor’s orders. The doctor may also enter orders from a remote location such as from his or her office computer. When paper charts are being used, the doctors’ orders are handwritten or preprinted on a paper doctors’ order sheet located in the patient’s chart binder. Preprinted orders are a typed set of orders for a specific diagnosis or procedure that has been approved for use in the hospital. The physician will have options for diagnostic and treatment orders that may be selected by marking the appropriate box or by placing a checkmark next to the order. Preprinted orders greatly reduce the potential for errors resulting from the inability of the health unit coordinator (HUC) to read the physician’s handwriting. Physician’s orders include such items as diagnostic procedures; medications; nursing, surgical, and other treatments; diet, patient activities; and discharge. As stated in Chapter 8, handwritten and preprinted doctors’ orders are legal documents that become a permanent record of the patient’s chart. The doctor writes all orders in ink, records the date and time, and signs each entry. Again, the doctor may write one order or a collection of orders that is referred to as a set of doctor’s orders. The doctor indicates to the nursing staff that a new set of orders is included by flagging the chart. Flagging techniques vary among health care facilities (e.g., they may involve dog-earing the order sheet or using a slide indicator on the side or top of the chart binder). New orders can be identified by the absence of symbols and by the absence of sign-off information. See Figure 9-1 for an example of a set of written doctor’s orders. Sometimes, the doctor may write new orders and forget to flag the chart. Always check for new orders before returning a chart to the area where it is stored. If the new orders are recorded at the top of the doctor’s order sheet, check to see if the orders are a continuation from the previous sheet. When orders are recorded near the bottom of the doctor’s order sheet instead of at the top, make diagonal lines across the remaining space so new orders will not be recorded there, and then continue to the following page (Figure 9-2). the doctor has ordered that the patient’s blood pressure (BP) be taken with the patient lying, sitting, and standing and that it be recorded three times a day (tid). A time sequence such as 0800, 1400, and 2000 is set up by the nursing personnel for the BP to be taken daily. This routine continues until it is changed or discontinued by the doctor. Another example of a standing order includes the following: This order means that the patient receives a regular diet on each day of the hospital stay unless the order is changed or discontinued by the doctor. Standing: In effect and given routinely until discontinued or changed by the doctor prn: In effect and given as needed by the patient until automatically discontinued or changed by the doctor One-time or short-series: In effect for one time or a short period; automatically discontinued when the order has been completed When CPOE has been implemented, the role of the HUC remains acting as the primary communicator in helping to coordinate patient care activities on the nursing unit. When orders have been entered into the computer directly by the physician, there are many tasks that must still be performed by the HUC. Orders for consultations are usually denoted by a telephone icon that appears next to the patient’s name on the computer screen. Documentation of the consultation phone calls in detail is important and is discussed in more detail in Chapter 18 (Miscellaneous Orders). Additional phone call requests include requests by the nursing staff for the HUC to page or place calls to physicians. Another responsibility of the HUC that results directly from a physician’s order is the coordination of patient discharge or transfer (which may be denoted by a “bed icon”). A physician may input an order that requires an outside appointment that must be scheduled and documented by the HUC. The tasks related to patient discharges, transfers, and scheduling of appointments are also discussed in Chapters 18 and 20. The physician may input a request for patient medical records from a different facility; this may require HUC follow-up. One icon that may appear next to a patient’s name in the computer as a direct result of CPOE is an order for the patient to be “NPO” (nothing to eat or drink). This is informational and can be an important icon for the HUC to verify in case the patient requests food or other hospital personnel need to verify the nutritional status. The HUC is responsible for many tasks that facilitate workflow related to doctor’s orders and patient care. These tasks include communicating with the bed placement or admitting department; requesting outside health records; coordinating and printing discharge paperwork; printing and labeling consent forms; updating unit forms such as admission, discharge, and transfer sheets as well as face sheets and labels; managing equipment and delivering equipment in the pneumatic tube system; and checking utility and supply rooms.
Health Unit Coordinator Role in Processing of Electronic, Preprinted, and Handwritten Doctors’ Orders
Doctors’ Orders
Categories of Doctors’ Orders
Standing (Continuing) Orders
Stat Orders
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Processing of Doctors’ Orders with Computer Physician Order Entry
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