The facility I work for now does not use OE to enter Nursing orders. We have an
electronic kardex (a profile in NUR) that autoprints near the end of the shift
for the handoff,so in order to make Nursing orders display there, we created an
intervention called Kardex with a CDS that is built to enable staff to
transcribe orders for Nursing, and that CDS is part of the profile via the
SCREEN component.
The facility I last worked for used the same kind of kardex in the same way,
and also used OE for Nursing orders, but only for very specific,
physician-issued, key orders. For example: DNR. Restraints. The entry of these
orders added an intervention in Process Interventions. Because only high-risk
type orders created an intervention, the intervention list stayed short. These
orders didn't have to be transcribed to the Kardex intervention screen; they
were included on the Kardex profile using the Order component. More common
orders, such as for ambulation, were simply transcribed to the Kardex CDS, and
documented on the Ambulation/Transfer/Bed Mobility intervention CDS that was
part of every care plan, and used by both Nursing and PT to show compliance to
the order, but also to chart additional information that is expected from these
disciplines, such as assist devices used, distance walked, activity tolerance,
etc.
>From following the L for many years, I get the sense that some facilities have
>many or all physician orders for Nursing set up this way, but have found that
>it can create a mess for the nurses in Process Interventions. Before you
>decide on the approach you want to use, you might want to compare common
>physician orders with the content of the screens for the core interventions
>you have in every care plan. If, for example, you have a screen for
>meals/appetite that's part of your documentation standards for all patients,
>and one of the orders you need to accommodate is "assist patient with eating",
>that screen might be the place to simply add a query for feeding assistance
>with a lookup with choices from none to total. The nurses would have to
>continue transcribing this order to their kardex, of course.
If you make every physician order for nurses an OE/NUR intervention order, you
could end up with a very congested care plan in Process Interventions, with
many screenless interventions that nurses will document only by filing the time
& date stamp, and even though there's lots of other information they should
chart that's associated with these orders, they won't chart it because they'll
feel they've already done all they are expected to do. If you DON'T set up all
orders this way, the nursing staff will have to memorize what goes on their
Kardex and what goes in OE, which could lead to serious error. Either way could
call for a lot of education of the staff.
You'll find a happy medium somewhere. A year from now, somebody else will be
asking the same question and you can write and let us know what you did and why
and how it worked. Good luck! Sharon
-------------- Original message --------------
From: alidalee gingerich <[EMAIL PROTECTED]>
Questions as to how all are using nursing orders:
Who builds them as OE category Nursing, with the type as nursing so they are on
the intervention list for the users or
Who builds them as just regular orders, not nursing type & the orders do not go
to the intervention list?
What do you all do for kardexs?
We have not been placing our nursing orders into Meditech, but will be changing
that process. I wanted to review how others used it since it could be 2
different processes.
Thanks much
AlidaLee Gingerich RN, BSN
Applications Specialist
Acute Care Nursing
Office 970-871-2452
Pager 970-870-5873
Everyone is raving about the all-new Yahoo! Mail beta.
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