Re: Physician Notification Guidelines

[Holly Sox, RN, RAC-C]

Delores,   I am learning recently not to consider anything "a given".   We have nurses who will write a telephone order for an antibiotic, with nothing to indicate what it's for.  And no nurses notes to describe the symptoms.   We were just cited by state for a resident who had very high white count.  We were doing chest X rays, and IV fluids and Urinalysis and all sorts of tests. All with orders written.  Finally went to hospital and had an abdominal CT which revealed a sacral decub that the nurses on the floor had forgotten to document and/or assess.  See, we have a treatment nurse who is supposed to keep up with wounds. And the nurses on the floor just weren't writing anything.  So, over the course of the week, in all the conversations with the MD/NP, no one ever thought to say, "Remember, she has a decub on her behind."    I do agree about the problem with "NO" and "NNO".  I dislike abbreviations in general, because so many times, what you think is a universally understood abbreviation is totally foreign to another person.      Holly Holly F. Sox, RN, RAC-C  Clinical Editor, Careplans.com www.careplans.com [EMAIL PROTECTED] ----- Original Message ----- From: [EMAIL PROTECTED] To: [EMAIL PROTECTED] Sent: Sunday, February 08, 2004 6:57 PM Subject: Re: Physician Notification Guidelines OK, what am I missing?  If you are writing a telephone order does that not indicate that you spoke with [notified] the physician?  Why do you have a check box to remind you to write the reason in the licensed notes?  Isn't that a given?  I urge all  nurses to stop documenting , in licensed notes: "NO"  and "NNO"   for New orders and no new orders this is causing more survey and legal problems as time goes by.  We can look at the order sheet and determine this, you must document why you call a doctor what the doctor said why the orders are changes or why the orders were not changed Delores We have a space that is marked for physician notification on our telephone order sheets.  It also includes a space for resident/responsible party notification.  It is great.  Just takes a check mark and it is considered done.  Of course, the reason, ect., is still documented in the notes, but the order sheets are a good prompt. Sherri   Delores L. Galias, RN, RHIT STATEMENT OF CONFIDENTIALITY: The information contained in this electronic message and any attachments to this message are intended for the exclusive use of the addressee(s) and may contain confidential or privileged information. If you are not the intended recipient, please notify D. Galias, RN, RHIT immediately at [EMAIL PROTECTED] and destroy all copies of this message and any attachments.  Thank you for your cooperation