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Documenting orders for medications

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Last Post by burnsh 8 years ago

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jessicaw

(@jessicaw)

Posts: 434

Prominent Member

Topic starter

Curious what workflows providers are using to document orders for medications such as B12 injections? Currently our providers note it in their dictation but there is not a clear reference for the nurse when the patient presents for a nurse visit to receive a B12 injection. We are a small clinic and the nurses feel that most of the time they are giving these injections based on the patients word. It would be nice if there was some documentation in the patients chart, that was easy for the nurse to find, letting them know that this medication was ordered and the frequency and expiration of order. The only way they can currently see that it was ordered is to read through dictations to find it documented.

We want to establish a new workflow for this and are trying to decide the best direction to take. Does anyone use a separate encounter type or form to have the providers enter these orders? Or do the providers add it as a Service or Test order?

Posted : November 18, 2016 9:20 am

jcollins

(@jcollins)

Posts: 107

Estimable Member

We have standardized around quicktext for standing orders for the few injectables we give:

Example: b12

.b12 ==

Parenteral replacement with b12 1000mcg weekly x4 then 1000mcg monthly x12. Repeat b12 level in 6 mos.

this verbage may be in a chart note as instructions at checkout or in an append of the most recent labs

we also title the nurse visit summary with B12 1st weekly ect ... so that only one MA has to find the original text. We thought about using no charge orders but it really didn't help us.

JJC

Posted : November 18, 2016 9:28 am

jsander

(@jsander)

Posts: 108

Estimable Member

We use referral orders for things like this. They're designed for it, with expiration dates and quantities. Our internal referral codes will usually be something like "XXXXX" because the code itself doesn't need to be unique.

Posted : November 21, 2016 12:52 am

guilfordmedical

(@guilfordmedical)

Posts: 203

Reputable Member

Our providers document under what Diagnosis the b-12 is linked to: " Pernicious anemia" or "b12 def". The clinical staff uses the Medication HTML template to document the injection and it is linked to the orders for the correct medication administered.

Our clinical staff also places pop-ups in charts to remind them of the frequency they are due to come in as well. (4 weeks, 6 weeks, etc.)

Posted : November 21, 2016 3:24 am

evanstaden

(@evanstaden)

Posts: 31

Eminent Member

We use test orders for all appointments that need to be scheduled including follow ups with providers and nurse visits, we also have a B12 test order. Why would you not use the ordering system? It works well and you can track compliance and preauths if need be. Our staff review orders when a patient comes in and sees what was ordered. We also display recent orders in all our encounter forms as well as last HPI, CPOE and Impression and Plan. When a MA or Nurse opens the Nurse Visit she can quickly review the orders and the last impression and plan from the encounter without having to dig through previous documents.

Posted : November 21, 2016 6:31 am

burnsh

(@burnsh)

Posts: 155

Estimable Member

We use medication orders and change it to a future date with a quantity (e.g., put the date in for a year from now and quantity for 12 if you want monthly B12 shots). The nurses then reduce the quantity from the order (which rises to the top due to the future date) every time the patient comes in - they also document the administration, which creates an order from the date it was actually administered. I think I've got that right, but I can check with our nursing team if you want more accurate details.

Posted : November 27, 2016 12:13 am

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