Miscellaneous Orders

Miscellaneous Orders

Chapter Objectives

On completion of this chapter, you will be able to:

1. Define the terms in the vocabulary list.

2. Write the meaning of the abbreviations in the abbreviations list.

3. List seven points of information that should be communicated to the consulting physician’s office when a consultation order is transcribed.

4. Explain the health unit coordinator (HUC) responsibilities regarding patient medical records from another facility (ordering, receiving, and scanning into a patient’s electronic medical record [EMR] or filing into paper chart).

5. Discuss the procedure for photocopying, sending, or faxing patient medical records.

6. Describe the role of the case manager, and identify the types of patients that would require a case manager.

7. Name at least eight services rendered by the social services department.

8. Describe the process the HUC would follow when scheduling an appointment for a patient to be kept after discharge.

9. List six tasks the health unit coordinator may have to perform when arranging for a patient to leave the hospital on a temporary pass.

10. List at least six miscellaneous orders that would require action by the HUC.

11. Explain the purpose of a parent teaching room or transition room on a pediatric unit.

Consultation Order

A request by the patient’s attending physician for the opinion of a second physician with respect to diagnosis and treatment of the patient.

A film that contains a greatly reduced photo image of printed or graphic matter.

Parent Teaching or Transition Room

Many pediatric hospitals and/or units have a patient room with a bed so a parent can stay with the child 24 hours a day. Parents, after training, will assume full care of the child while they still have the support of the nursing staff. The child may then be discharged home to the parents’ care.

Abbreviation	Meaning	Example of Usage on a Doctor’s Order Sheet
appt	appointment	Schedule an appt with dental clinic
DME	durable medical equipment	Contact DME supplier for hospital bed for home
DNR/DNI	do not resuscitate and do not intubate	DNR or DNI
NINP	no information, no publication	Pt requests NINP
Rx	treatment, therapy, prescription	Disch in a.m. c¯ Rx
wk	week	Disch, F/U appt in my office in 1 wk

EXERCISE 1

Write the abbreviation for each term listed.

2. no information, no publication

3. durable medical equipment

4. do not resuscitate

5. medication, pharmacy, prescription, prescribe, take

EXERCISE 2

Write the meaning of each abbreviation listed.

Consultation Orders

Background Information

The attending physician of a patient may wish to obtain the opinion of another doctor (specialist or surgeon) regarding diagnosis and/or treatment. The request for another doctor’s opinion is written in the patient’s electronic medical record (EMR) or on the doctors’ order sheet by the patient’s attending doctor or by a hospitalist, or resident (at the attending doctor’s request); this is called a consultation order. The ordering doctor may specify that the consulting doctor is to consult only (write opinions and recommendations) or may also write orders.

HIGH PRIORITY

When the electronic medical record (EMR) with computer physician order entry (CPOE) is implemented, the physicians’ orders are entered directly into the patient’s electronic record. Many of the miscellaneous orders discussed in this chapter involve action to be taken by the health unit coordinator (HUC). When the doctor enters orders into the computer, an icon (usually a telephone) is displayed on the nursing unit census screen (next to the appropriate patient’s name) to alert the HUC that there is a task to be performed. The most common doctors’ orders that require HUC tasks when EMR is used include the following:

• Patient consultations

• Obtaining patient medical records from another facility

• Scheduling postdischarge appointments

• Surgical or procedure consent forms (covered in previous chapters)

• Discharge and transfer orders (covered in Chapter 20)

HIGH PRIORITY

Downtime requisitions are included in this chapter for learning purposes. The Evolve website associated with the Health Unit Coordinator Skills Manual includes a simulated hospital computer program that may be used as well.

Processing a consultation order usually requires that the health unit coordinator (HUC) notify the office of the requested doctor regarding the order. Prepare for the call to the doctor’s office or answering service by writing the doctor’s telephone number on a notepad; have the patient’s chart close by so any additional requested information may be accessed easily. When you are speaking to the staff member in the doctor’s office, the patient’s insurance information may be requested. If the doctor’s office is closed and the consultation is relayed to the answering service, the doctor’s office secretary may call back for the patient’s insurance information. It is important to document the time of the notification and the name of the person or operator number (answering service) spoken to. When EMR is used, the documentation is entered into the patient’s EMR or the HUC communication screen and when paper charts are used, the documentation is written next to the order on the doctors’ order sheet. In transcribing written orders in a patient chart, write this information next to the order on the doctors’ order sheet, and initial it. The process in an EMR system usually requires timely updates in the computer when the office has been called and when the physician has actually been reached and returned the call. Documentation of calls, contact names, and times is as important with EMR and computer physician order entry (CPOE) as it is when transcribing paper-based charts. With the implementation of EMR, the time spent by the HUC making consultation and other telephone calls may be a significant portion of the tasks performed.

Note: Some hospitals may have a policy that requires the requesting doctor to notify the specialist personally, so patient history and additional information may be provided.

The following information should be communicated to the office of the consulting doctor:

• Hospital name

• Patient’s name and age

• Patient’s location (unit and room number)

• Name of the doctor requesting the consultation

• Patient’s diagnosis

• Urgency of consultation and any additional information provided on the order

• Patient’s insurance information, located on the patient’s face sheet

After interviewing and evaluating the patient, the consulting doctor will dictate his or her findings and recommendations. A hospital medical transcriptionist will then compile the consultation report and send it to the nursing unit, and the HUC will file the report in the patient’s chart (Fig. 18-1). When the EMR with CPOE is implemented, the physician will enter findings and recommendations directly into the patient’s EMR via computer. The consulting doctor will take a copy of the patient’s face sheet back to the office for billing purposes.

Figure 18-1 Dictated and typed consultation report.

Doctors’ Orders for Consultation

Doctors’ orders for consultation may be expressed in writing on the doctors’ order sheet as follows:

• Notify Dr. Cynthia Avery from Valley Anesthesia to eval for CABG surg

• Call Dr. Paul Reidy (Valley Surgeons) for consultation only

• Call Dr. Philip Vasquez to see patient re radiation therapy

• Have Dr. Jackson Williams Westside ENT see patient today—may write orders

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Tags: LaFleur Brooks Health Unit Coordinating

Apr 8, 2017 | Posted by admin in MEDICAL ASSISSTANT | Comments Off

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