Part 2

Hospital Settings Requisitions, and Reports

 Hospital Related Responsibilities

❑ When a patient goes to the operation

room, all existing orders are usually
considered void until reordered
❑ Clients booked for surgery, particularly
elective surgery, will have a designated
time for the surgery assigned by the OR.
❑ A surgical schedule is posted outlining the
surgeries booked for the following day
 Processing Physician’s Orders
❑ The physician’s orders must be
proceeded ASAP after a
patient is admitted
❑ The orders are transferred to
the appropriate requisitions
line by line (the responsibility
of a ward clerk!)
 Doctors’ Orders
Doctors’ orders cover such things as:
 Type of care,

 Tests,
 Medications,
 Level of activity,
 Diet,
 Nursing and therapeutic interventions
 Doctors’ orders
❑ Orders are typically written by
the hospitalist or most
responsible physician (MRP).
❑ When a patient is admitted to the
hospital, it is common that the family
physician or specialist relinquishes
their right to write orders to the MRP.
 Doctors’ Orders
Before an order can be
processed, it must
 Be clearly labeled with the
patient’s name, birth date,
and health card number
 Be signed by the ordering
physician.
 Doctors’ orders
❑ The orders are recorded on a patient data
profile screen or document called a Kardex
and stored in the patient's paper-based or
e-chart.
❑ The precise format of a Kardex varies
between clinics and specialties.
Kardex
 Order entry: The Process
Step 1, Be aware of a newly written order
 This is easy when the patient has just been
admitted or returned from the operating
room.

 It is harder to catch the unexpected orders.

 To notify staff that an order has been written,

it is common for the doctor will “flag” the
chart.
 Order entry: The Process
Step 2, Review the orders for
anything urgent (stat)
❑Stat orders must be processed immediately.
❑They may include medications, intravenous
therapy, blood work, and diagnostic tests.
 Order entry: The Process
Step 3, Process the orders
❑ Enter the highest priority orders
first.

❑ Process each order individually

❑ ~ Think each order through.

❑ Ask yourself what else needs to be

done. (Is there someone to call?
Should I tell the nurse? Does the
order make sense for this
particular case?)
 Order entry: The Process
Step 4, Identify the order as
complete.
 Every facility will have a commonly used
code to identify when the process has
been completed.

 What the code is irrelevant; the fact that

you must use one is not.

 This code will go a long way to

keeping you organized and
preventing errors.
 Order entry: The Process
Step 5, Recheck your orders
 Sequentially, carefully, and
thoroughly.

Step 6, Have your orders checked by

the nurse
 This takes a bit more time but is
well worth it for the patient’s
safety, and your peace of mind.
 If an error occurs and you do not
have the orders validated, you
may be held legally responsible.
 Order entry: The process
Step 7, Sign off. Before signing off, check once more to ensure that the patient’s name on
the orders and the name on the MAR match.
 Order entry: The Process
Step 8, Send to the pharmacy
 Once it has been sent, note on the
order the time/date this was done.
Step 9, Return the chart to its
proper place
 This keeps the desk area tidy and
prevents charts from being
misplaced or lost.
 If the chart was flagged, remove the
flag.
 “Flag” System
 A “flag” system is used for inserting-
coloured tags for the chart that contains
NEW orders.
 The ward secretary should check the
charts at the beginning of the shift and
then periodically during the shift
 Transcribing Medication Orders
 All medications taken by the patient
while in the hospital must be ordered
by the physician at the hospital.

 Even those routinely taken must be

ordered if they are to be continued
while in hospital. E.g. birth control pills

 This prevents potential over-dose,

contraindication, or interference with
lab tests.
 Transcribing Medication Orders
 Routine medication orders
must be taken at a specific
time, be it at certain hours in
a day or a certain day in a
week.

 Some scheduled
medications are taken for a
designated time, others
indefinitely.
e.g. antibiotics for 8 days
 Common Abbreviations Used
 a.c., ac Before meals
 ad lib Freely, as desired
 APAP Acetaminophen
 b.i.d., bid  gtt Drops
Two times a day
 c-  h Hour
With
 Caps  h.s., hs At bedtime
Capsules
 Cc Cubic centimeter
 gm, g Gram
 Commonly Used Abbreviations
 mg Milligram Milligram
 ml, mL Milliliter Milliliter
 NPO Nothing by mouth Nothing by mouth
 NSAID Nonsteroidal anti-inflammatory drug
 p- After
 p.c., pc After meals
 PO, p.o. po By mouth
 p.r By or through the rectum
 p.r.n., prn As needed, as necessary
 Pt Patient
 q Every
 q.h., qh Every hour
 q2h Every 2 hours
 q.i.d., qid Four times a day
 Common Abbreviations Used
 qAM Every morning
 qPM Every evening
 Rx Prescription
 s- Without
 SL Sublingual
 s.o.s. If it is necessary/needed
 SQ Subcutaneous
 tab Tablet
 t.i.d.,tid Three times daily
Processing Physician’s Orders
1. CBC & ESR (Complete blood count & Erythrocyte )
2. Weight please
3. Dietician to see
4. 1200 Cal DD, NAS Diabetic Diet, No added Salt
5. Urine check twice, ac=before meal, hs-bedtime
6. FBS= fasting blood sugar
7. BS=blood sugar before lunch ac=accuchecks
8. Tylenol #2 1 tab every 8 hours prn – as needed
9. Halicon 0.25 mg as needed before bedtime as needed
10. BRP=Bathroom Privileges
11. LES= laxatives as needed
12. CXR chest X-ray
13. ECG electrocardiogram
14. BUN =blood urea nitrogen
15. Lytes= sodium, potassium, and chloride
16. Proteins in urine,
 Transcribing Medication Orders
Discontinuing existing orders
❑Orders are discontinued if there is
an automatic stop date and/or the
doctor does not renew.
❑This must be noted in the MAR by
marking d/c beside the medication.
 Transcribing Medication Orders
 Loading dose

 This is a higher-than-usual
dose of a medication
given to rapidly increase
the level of the medication
in the bloodstream. e.g. an
antibiotic for a severe
infection
 Transcribing Medication Orders
Medications with special directions
The doctor may write a medication order with specific directions regarding dose or time of
administration. e.g. Lasix 40 mg po bid starting Jan 3 @ 1000 hours
 Transcribing Medication Orders
 Sliding scale orders
 Sometimes, a doctor orders a drug with a dosage on a
sliding scale – that is, to be adjusted on the basis of test
results.
e.g. Insulin dosage dependent upon blood sugar reading
 Postoperative medication orders
 All pre-operative orders are discontinued and need to be
reordered.
 Computerized Physician Order Entry
 Some facilities have introduced a virtually paperless order
system called computerized physician order entry (CPOE).
 The clinical secretary is still responsible for ensuring that the
orders have been transferred to the department responsible,
notifying the appropriate person or department of orders
requiring immediate attention.
 Some hospitals have mobile computerized
medication carts.
 Discharge and Transfer Procedures
Discharge
When the physician decides that the patient is well enough to
go home, they will write the discharge orders.
You need to:
 Notify the patient, nutritional services, and
housekeeping
 Assemble any discharge information the patient requires,
collect any valuables that were locked away
 Discharge and Transfer Procedures
Discharge
 The discharge orders will include any:
 follow-up medical appointments,
a list of current medications, and
discharge teaching materials.
e.g. keep the surgical site clean and dry.
 Discharge of a Patient
 The ward secretary/clerk is responsible for disassembling the
chart when a patient is discharged from the unit
 An out-patient chart is usually kept on a clipboard
 An in-patient chart is kept in an individual binder for each patient
 In both cases, the chart needs to be in a specific order on
return to the Health Record Department
 This order is dictated by hospital protocol
 Discharge of a Patient (cont’d)
 The ward secretary will check the chart to ensure that all
necessary signatures and initials are there (i.e. all orders must be
signed by the physician)
 The medication sheets will be taken from the MAR (Medication
Administration Record) binder and inserted into the patient’s
chart
 Once the process is complete, the ward secretary sends the chart
to the Health Records Department
 Discharge and transfer procedures
Transfers
 Sometimes, clients are transferred from one unit to another
with the facility, usually on a doctor’s order for medical
reasons or receive surgery.
 The patient's chart, belongings, medications, hospital
card and MARs go with them.
 Unauthorized Departures
 AMA – “against medical advice”

 If a patient insists on leaving the hospital without a physician’s

order, they must sign a release form stating that they are leaving
without permission.

 Deaths

 When a patient dies, a doctor confirms that the patient is

deceased and a death certificate must be completed and
signed by the doctor.
 The morgue is called to remove the body.
 Other Standard Files And Resources

 Requisitions are simply order forms requesting and authorizing a

diagnostic test.
 Community Agency forms are similar to referral forms in that they are a
formal request from a physician on behalf of the patient so that they may
receive specialized care.
 Security and Emergency Codes
 Hospitals by their nature are subject to a daily risk of emergencies.
 All hospitals use a set of “universal codes” to alert staff of a variety
of emergencies, without upsetting patients.
Hospital Codes for Emergency
 Security and Emergency Codes
 Know the protocol.

 Know your role.

 Stay calm.

 Gather accurate information.

 Promptly notify the appropriate persons.

 Confidentiality
 Confidentiality is defined as “entrusted with secrets”
 In medical field this term applies to patient identification as well
as patient information, diagnosis, prognosis, and medical records
access (manual or computer)the
Questions?