TREATMENT ORDERS Curriculum
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Kwantlen Polytechnic University *
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Apr 3, 2024
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TREATMENT ORDERS – HUC104
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DOCTOR’S ORDERS
Doctor’s Orders are handwritten or preprinted on a doctor’s order sheet, usually located in the patient’s chart binder. Preprinted orders are a typed set of orders for a specific diagnoses or procedure that will have been approved for use in hospitals. Preprinted orders greatly reduce the room for errors resulting from the inability of the HUC to read the physicians handwriting. An example of preprinted records and physician orders is called FormFast, or Form Imprint. Here is an example of what it looks like. You would choose the correct patient, choose what you need printed, and voila, out comes a form, already labelled with the patient’s information, and it is ready to go:
Physicians Orders include such items as diagnostic procedures, medications, nursing, surgical and other treatments, diet, patient activities and discharge planning. Handwritten and Preprinted Orders are legal documents that become a permanent record of the patient’s chart. The Doctor writes all Orders in ink, records the date and time and signs each entry. If a Physician Order has no signature, legally it should not be processed. You would inform the Nurse or Charge Nurse that the
order has no signature and it is up to them to obtain one from the physician. The doctor may write one order or a collection of orders that is referred to as a set of doctor’s orders. The doctor will indicate that there are new Order’s by flagging the chart. 2
New orders can be identified by not only the flagging system, but the absence of symbols and by the absence of sign-off information. It is good practice to check charts even if they are not flagged for new orders. Physicians are humans and make errors as well.
If the new orders are recorded at the top of the doctor’s order sheet, check to see if the orders are a continuation from the previous sheet. When orders are recorded near the bottom of a blank doctor’s order sheet instead of at the top, make a diagonal line across the remaining space so new orders will not be recorded there.
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Doctor’s may also call the Nursing Unit to give a telephone or verbal order. All Telephone and verbal orders must be directed to a Nurse, even if it is for something as simple as: Mr. Smith can now eat, his surgery has been postponed
. A HUC is not authorized to take a Telephone or Verbal Order from a Physician.
Processing Orders with CPOE:
A physician will write an order as usual, either via a Handwritten Physician Order or a Preprinted Physician Order. Once written it will be flagged for the HUC to Process.
The HUC will then Process the Physician Orders using the hospital Computer Order Entry System.
This link will show you how to process an Order in CPOE: http://www.kloudlite.org/Meditech/
Remember: the hospital you get hired at may not use this OE program exactly and may differ a little bit, but once hired you get trained on the computer system used.
Symbols:
As the HUC completes a part of the transcription procedure, a symbol that consists of words or letter(s) is
recorded on the doctor’s order sheet to indicate completion of the task. The symbol is to be written in red ink.
By using the symbols, the HUC provides a written record of the steps completed which reduces the possibility of omitting or forgetting to complete a part of the transcription procedure. There are constant interruptions on a nursing unit and this could make it easy to forget where one left off when returning to transcribing a set of orders. Lack of order completion can cause delays in treatment, which may cause delays in or be harmful to the patient’s recovery.
Every physician order must be symbolized that it has been processed.
Symbols very amongst hospitals, but not by much.
Here is a list of symbols used by most facilities:
Faxed, scanned
– indicates that the pharmacy copy of the doctor’s order sheet was forwarded to the pharmacy. You must also use a FAXED/SCANNED stamp on the physician order sheet when anything is sent to the pharmacy. Most stamps are located on/near the fax machine/scanner. O/E, I/C
- (order entered, in computer) – indicates that the order has been entered into the CPOE system
K
- indicates the order has been transcribed onto the Kardex Form
MAR
– indicates a transcription of a medication order on the MAR form.
aware, notified
– indicates that the person/specialty requested to be informed has been informed. For example, if you need to call the lab technician for stat bloodwork, you would write: lab aware
There is also Miscellaneous symbolization used, for example, if a physician writes: DNR
as an order, you would not transcribe that as that legally has to be on a MOST order, so your symbolization would be: see MOST
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Steps for Transcription of Doctor’s Handwritten or Preprinted Orders:
1. Read the complete set of doctor’s orders
2. Scan for STAT orders. These orders should always be processed first.
3. Order medications by faxing or scanning a copy to the Pharmacy department
4. Transcribe all medication orders onto the MAR (medication administration record)
5. Order any diagnostic tests or laboratory tests as required.
6. Kardex all treatment Orders.
7. Recheck each step for accuracy and thoroughness
8. Sign off the completed set of doctor’s orders
9. Flag the chart for the Nurse
There may be more than one patient on the unit with the same name. Always make sure you check, and double check the patient information. Match their names, Date of birth and Personal Health Number to be sure you have the Correct patient’s chart, MAR and Kardex Form
. Any stat orders should not only be processed via OE
, K
, and MAR
, but the appropriate person/department should be notified immediately that there is a STAT order pending. Symbolizing a physician’s order:
Notice
how all the symbolization is in a) red, and b) to the right of the physician order, in unison. 5
Notice how each physician order entry, for that time, is signed off by whoever processes the physician order.
Notice
how the ‘faxed’ stamp is to the right of the physician order, but does not overlap any symbolization. HUC Role in Processing of Electronic, Preprinted and Handwritten Orders
There are four methods a Doctor Uses to provide Orders:
1. Electronically (EMR)
2. Handwritten Orders
3. Preprinted Orders
4. Telephone Orders.
Recognizing New Handwritten Doctor’s Orders:
The Doctor Indicates a new set of orders by flagging the chart. Flagging techniques vary, most common techniques are:
- slide indicator on the side or top of the chart binder
- dog earing the order sheet Slide indicators are usually located at the front of the chart and look like this:
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When a physician writes a new order:
1. The chart gets flagged. In this example, the chart is flagged with the Tab that states “Doctors Order (STAT)’ 2. The HUC then takes the chart, and processes the Orders.
3. Once the Order is processed by the HUC, the HUC slides the “Doctors Order: tab down and pulls up the tab that says “Nurse to check’. This then flags the Nurse to check the chart as there are now new processed Physician Orders that pertain to the treatment and care of the patient. It is not the responsibility to notify the Nurse or new orders UNLESS there are STAT orders, in which case the HUC must notify the Nurse that the pt has new STAT orders.
Many charts have different tabs that are not all used by a HUC:
For example, in the above picture, the tab that states ‘Doctor Alert’ would be used by the Nurse or a Multidisciplinary Team Member to alert the physician to look into their notes. The patient may have loose
stools and needs medication for constipation. Or maybe the patient is choking when swallowing so the dietician has requested the Physician order a liquid diet. There are many reasons that this Tab would be used, but it is not one used by the HUC. A Flagged Chart looks something like this:
Categories of Physician Orders:
1. Standing Orders: in effect and are executed routinely as ordered until they are discontinued or changed by a new doctor’s order. Some examples of standing orders are Dietary or Activity orders.
2. PRN: given as necessary or until changed or discontinued. Medication orders are not the only orders that can be prn orders. For example, and order can be written for a pt to use a walker prn. 7
3. One time or short-series: treatment or medication carried out once only for a short period of time. For example, an order can be written for a patient to have a day pass tomorrow morning.
4. Stat: an order that is carried out immediately.
HUC Role in Processing Physician Orders with CPOE:
1. Coordinate patient care activities on the nursing unit.
For example, if the pt. has to be with Physio at 1300 hours, but has an X-ray appointment at 1315hrs, the NUC would notify the Physiotherapist that they would have to change their time due to the X-ray. It would be the role of the HUC to know what to prioritise. 2. Places and documents calls made for consultations and scheduling of outside appointments.
Many Units have a Call Log Sheet. This is for the HUC to use so that you can keep track of who has been
called and for what purpose, and have they called back. This is not part of a medical record, more a tab for the HUC to keep track of who was called and for what purpose.
3. Completes tasks related to patient discharges and transfers.
This not only includes CPOE, but also includes dismantling the patient chart and preparing it to be sent to
the Medical Records department. And includes getting the room cleaned when the patient leaves and letting the CN know the room is now ready for a new admission. Also, the HUC should note the discharge in the ADT book on the unit.
Transcription of Doctor’s Handwritten or Preprinted Orders:
A process that is used to communicate doctors’ orders to the nursing staff and other hospital departments.
The transcription procedure includes:
-
Kardexing
-
Ordering
-
Using Symbols
-
The signing off Process
Kardex Form:
Each nursing unit may use a portable file that is referred to as the Kardex, which contains one Kardex form for each patient on the nursing unit. Kardex’s are usually kept together in a Filing System, that allows for easy flipping. Most common Kardex holders look like this:
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Each clear slot allows for one Kardex per patient. The clear slots allow for easy visibility. The Kardex is held in by the corners: The Kardex is not part of the patient’s medical record, therefore when the pt is Discharged, the Kardex can be discarded into the Shredder Bin.
Five Main areas common to most Kardex forms:
-
Activity
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-
Diet
-
Vital sign frequency
-
Treatment
-
Diagnostic studies
The purpose of the Kardex is for a quick reference for the nursing staff. It has the current profile of patient’s information, current physician orders (non-medication) and current patient nursing needs.
It is used for planning and designating patient care and reporting patient information to the oncoming shift.
The process of recording all new Physician Order’s onto a Kardex is as follows:
-
All physician orders are done in PENCIL. This is because a patient’s orders may change, and it is
one Kardex per patient per hospital stay. -
Information not subject to change can be recorded in black/blue ink. This could be the initial Attending physician, or the patients Next of Kin.
-
Allergies are always written in red ink. -
Accuracy is essential
Example of a completed Kardex Form:
What to do if you have no more room in a section to transcribe an order:
If for some reason, you have no more space in a section to transcribe a new order, you can use the MISC TREATMENT section as needed.
Example: This patient has a few I/O orders, none of which can be erased yet as they are still valid:
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The dr has now written a new order: check for urinary stones, use strainer.
There is no space in the I/O section, so you would continue with this new order under the MISC TREATMENT section:
KARDEX FORM – indenting
When you have on order that takes more than one line on the Kardex, indent the lines after the firs one. Example: Ordering:
This is the process of transcribing and inputting the Physician’s Order into the computer or on paper.
Ordering by computer requires the HUC to:
-
select the patient from the computer database
-
follow the steps to input the ordering information. This is based on the hospital computer system used.
Symbols:
A symbol is recorded on the doctor’s orders sheet to indication completion of a task. The symbol is to
be written in RED INK at the end of the Physician Order for each order.
Example: 11
Accuracy during the transcription procedure is a must. Errors may cause serious harm or delay in treatment for the patient.
There will always be differences in what is done in the classroom, between hospitals and even between nursing units within hospitals.
All orders must be signed off by the person who has transcribed them
.
For example, as a HUC you would sign off in red ink with HUC and your Initials.
HUC AZ
As a student, you will be signing off as: Student HUC and your initials
, in red ink Responsibilities to change an Order on the Kardex when one is written.
When the physician wants a change in the order, but it has to do with the same treatment, the usual practice is to erase the previous order and write the new one with the current date
. If you have enough space to keep all orders, you can. For example:
Existing Order: NPO
New Order: DAT K, OE
Existing Order: BR x 24 hours
New Order: AAT K
Existing Order: IV SL
New Order: IV NS @ 125 cc/hr K
Existing Order: O2 NP prn
New Order: D/C O2 K
The HUC is to erase the old existing order on the Kardex, and write the new order as it is in the Physicians Orders. The only time the ‘erasing’ rule does not apply is for Laboratory and Diagnostic Orders, and some Miscellaneous Orders we may come across. (this will be looked into more in the future courses)
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Steps for automatically cancelling and discontinuing doctor’s orders.
1
. Read the orders.
2
. Obtain the Kardex form
3.
Document the automatically cancelled orders by:
a. erasing the existing date and order
b. writing the date and new order in pencil in the appropriate column on the Kardex
c. writing K on the physician order sheet to indicate completion of the documentation
Patient Activity, Positioning and Nursing Observation Orders
Patient activity Orders
:
Patient activity refers to the amount of walking, sitting and other motions the patient may do in a given period during a hospital stay. The prescribed activity changes to coincide with the patient’s stage of recovery. For example, after some major surgical procedures, the doctor may prefer that the patient remain in bed. As the patient recovers, the doctor increases the level of activity accordingly. Common Doctor’s Orders for patient activities: CBR: the patient is to remain in bed at all times; complete bed rest
BR BRP: the patient may use the bathroom for the elimination of urine and stool but otherwise must remain in bed; bedrest with bathroom privileges
Dangle: the patient may sit and dangle his or her legs and feet over the edge of the bed
Bedside commode: the patient may use a portable commode at the bedside
Up help: the patient may be out of bed when assisted by a member of the nursing staff
Up in chair: the patient may sit in a chair
BRP when A&O: the patient may use the bathroom when alert and orientated
Up in hall: the patient may walk in the hall
Up ad lib: the patient has no restrictions on activity; AAT
OOB: the patient may be out of bed
May shower: the patient may have a shower
*
All activity orders are to be transcribed on the patient Kardex in pencil in the ACTIVITY section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization for the above orders would be: K
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Common Doctor’s Orders for patient positioning: Patient positioning is often determined by the nursing staff; however, the doctor may want the patient to remain in a special body position to maintain alignment, promote comfort and facilitate body functions. ↑ HOB 30
° : the head of the bed is to be elevated 30 degrees
↑ lt. arm on 2 pillows: the left arm is to be elevated on two pillows
Turn to unaffected side: the doctor wishes the patient to lie on the side that is free of injury
Flat in bed x 8 hr, no pillow: the patient is to remain in bed for 8 hours, after which the standing activity order is resumed
Turn q2h: the patient’s position is changed every 2 hours to prevent skin breakdown
*
All positioning orders are to be transcribed on the patient Kardex in pencil in the POSITION section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization for the above orders would be: K
Common Nursing Observation Orders:
The doctor will often write a nursing observation order for periodic observation of the patient’s condition, referred to as signs and symptoms. Some doctors may write ‘call’ orders if they want to be called in the event of a certain circumstance. This does not mean that
the HUC calls the physician, it means the Nurse would call the physician if needed. VS q4h: the patients vital signs are to be taken and recorded every 4hours
BP qhx4: the blood pressure is to be taken and recorded every hour for four hours
Observe SOB and notify MD: the patient will be observed for shortness of breath and if severe, the nurse will notify the physician of the patient’s condition
Check pedal pulse rt. foot q2h: pulses are obtained from an artery on top of the foot every 2 hours
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*
All Vital Sign orders are to be transcribed on the patient Kardex in pencil in the VITAL SIGNS section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization for the above orders would be: K
NVS q4h until stable: the patient’s neurological vital signs are taken and recorded every four hours until stable
*
All Neuro Vital Sign orders are to be transcribed on the patient Kardex in pencil in the NUERO CHECKS section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization for the above orders would be: K
Accu-check qid ac and hs: accu-check is a type of blood glucose monitor. The doctor has ordered the test to be done four times a day before meals and at the hour of sleep. *
All Blood Glucose Monitoring orders are to be transcribed on the patient Kardex in pencil in the ACCUCHECKS section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization for the above orders would be: K
Pulse Oximetry q4h: oxygen saturation is to be measured every 4 hours
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*
All Oxygen Saturation Orders are to be transcribed on the patient Kardex in pencil in the RESP SUPPORT section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization for the above orders would be: K
I&O: the patients fluid intake and output are measured and recorded at the completion of each shift to monitor the patient’s fluid balance
U/O q2h: the patients catheter bag contents would be emptied and measured every 2 hours
*
All I&O and U/O Orders are to be transcribed on the patient Kardex in pencil in the INTAKE/OUTPUT section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization for the above orders would be: K
Wt. daily: the patient is to be weighed daily and the weight is to be recorded.
*
All Weight Orders are to be transcribed on the patient Kardex in pencil in the WT. section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
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Symbolization for the above orders would be: K
Nursing Intervention or Treatment Orders
Nursing Intervention or Treatment Orders
: a nursing intervention is any act performed by a nurse that implements the nursing care plan or any specific objective of the clinical plan or pathway, such as turning
a comatose patient to avoid development of ulcers, or teaching insulin injections to a diabetic patient before discharge. Interventions may include support measures, activity limitations, administration of medications, or treatments given to relive the current condition or to prevent the development of further stress. Common Doctor’s Orders for Intestinal Elimination: NS enemas until clear: the patient is to receive normal saline enemas until the elimination is clear Rectal tube prn for distention: the nurse is to insert a rectal tube so that the patient can relieve some gas and perhaps not be so distended *
All Intestinal Elimination orders are to be transcribed on the patient Kardex in pencil in the MISC TREATMENTS section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization used on the physician order for the above two examples would be: K
Common Doctor’s Orders for Catheterization and/or Bladder Treatment Orders: May cath q8h prn: the nurse can place a catheter every 8 hours so the patient can urinate, as needed. If the
patient urinates on their own, the catheter is not needed.
Cath in 8h if unable to void: the nurse is to insert a catheter into the patient in 8 hours if they do not urinate before that.
DC cath in am: the nurse is to remove the catheter in the morning 17
*
All Catheter or Bladder Treatment Orders are to be transcribed on the patient Kardex in pencil in the I/O section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization used on the physician order for the above examples would be: K
Common Suctioning Orders:
Suction throat to clear airway prn: the nurse is to suction the patient’s airway whenever it needs clearing
NG to LIS: the nurse is to connect the patient’s nasogastric tube to a low intermittent suctioning device
*
All Suctioning Orders are to be transcribed on the patient Kardex in pencil in the MISC TREATMENTS section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization used on the physician order for the above examples would be: K
Common Heat and Cold Application orders:
Hot compressors to abscess on lt. ankle 10min qh: the nurse is to apply a hot compress to the patient’s ankle for ten minutes every hour
Ice to scrotum as tol x 24hr: the nurse is to provide ice packs to the patient so they can apply it to their scrotum for the next 24 hours, as tolerated
*
All Heat and Cold Application Orders are to be transcribed on the patient Kardex in pencil in the MISC TREATMENTS section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization used on the physician order for the above examples would be: K
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Intravenous Maintenance and Blood and Blood Product Orders
Intravenous Therapy:
The word intravenous (IV) means within or into a vein. An IV consists of a needle inserted into a vein usually in the lower hand or arm that is attached to tubing leading to a large bag of fluid. The fluid which is ordered by the physician to carefully control the patient’s fluid intake may
supply proteins, dextrose, electrolytes, minerals and vitamins.
Medications are also given by IV, and are either added to an IV solution in a separate bag infused along with the IV solution or are inserted directly into a saline lock. The RN’s are responsible for:
-
Starting an IV on a patient once ordered
-
Hanging new bags of IV solution
-
Changing an IV to a saline lock when ordered
-
Discontinuing an IV or saline lock once ordered
Some hospitals have specialty IV nurses who are called upon when the Nurse has a difficult time starting an IV. If this is the case, the Nurse will let you know and ask you to contact the IV nurse, usually by phone, to help with a difficult IV start for a patient. No written physician order is needed for this. If there is an order for a PICC insertion, the HUC would transcribe this on the Kardex and call/notify the PICC team (usually one team in the hospital) that there is an order pending. The RN would not be qualified to insert a PICC
Identifying an IV order
: IV orders are generally written in the following format:
IV
Solution
Flow Rate
IV
D5NS
@ 125 cc/hr K
IV
RL
@ 100 cc/hr x 2hrs, then DC K
If a medication is written in the IV, this is written as follows:
IV D5W 500 mgs Aminophylline/l @ 100mls/hr This would be transcribed on the MAR
, and not on the Kardex. Sometimes the physician will include volume (size of bag) of IV solution to be infused:
IV 1000cc D5W 500 mg Aminophylline/l @ 100 mls/hr. The above two orders would be transcribed on the MAR, and not on the Kardex. Symbolization would be MAR, Faxed
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If a physician wishes the patient to have a large volume of fluids immediately, the order will be written as
a bolus in the following format. In this case, the RN should be advised of the order as soon as possible:
IV 500ml bolus D5W The above order would be symbolized with: K, RN aware
Volume:
IV solutions are kept on the nursing units. They are supplied by the Stores Department in 500ml
and 1000 ml plastic bags. Common IV solutions: (
all should be processed with the symbol K on the physician’s orders
)
1. 5% D/W (D5W) = 5% dextrose in water
2. 5% D/S = 5% dextrose in saline
3. 2/3 1/3 = 2/3 dextrose and 1/3 saline
4. Normal saline (NS) – saline solution
5. D5 ½ NS = 5% dextrose in ½ strength normal saline
6. D5 ¼ NS = 5% dextrose in ¼ strength normal saline
7. D5 LR – 55 dextrose in lactated ringers
8. 5% D/W 20 mEq KCL/l = 5% dextrose in water with 20 milliequivalents or Potassium chloride per litre
Saline Locks:
A saline lock is the IV needle that a patient has inserted into their hand which can be attached to an IV solution, or in the case where a patient no longer needs a continuous solution infused, is used when a patient requires intermittent IV medications to be given. Some time ago they were called Heparin Locks because a small amount of Hepalean was inserted in the lock to keep it open. Then it was discovered that a saline solution will perform the function, so they are now called Saline Locks. Orders for Saline locks are similar to the following;
1. SL IV =
saline lock IV
2. IV to SL WDW = IV to SL when drinking well
Symbolization for processing of the above 2 orders would be: K
*
All IV Therapy orders are to be transcribed on the patient Kardex in pencil in the IV FLUIDS/RATE section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
BLOOD and BLOOD PRODUCTS
Blood and blood components are also infused through an IV, however, remember the old saying ‘blood is thicker than water’ – so it requires a larger IV needle to be inserted.
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Some examples of Blood and Blood Products are packed red cells, fresh frozen plasma and platelets. We will be going through this in more depth when we do our course of Laboratory Transcription.
Some common transfusion of blood orders, blood component orders and plasma substitute orders are:
Give 2U of whole blood now: The nurse is to administer 2 units of blood when received from the laboratory. This is considered a stat order which the HUC would have processed. Symbolization for the above order would be: K, lab aware, RN Aware
Give 2U FFP K, lab aware
. The nurse is to administer 2 units of fresh frozen plasma when received from the laboratory
T and X match 2U PC and hold for surgery: Type and Screen 2 U of Packed Cells and have them held for surgery K, lab aware
. This is an order that the HUC would process to the laboratory.
Symbolization for the above orders would be: K, lab aware
*
All Transfusion of blood, blood component, and Plasma Substitute Orders are to be transcribed on the patient Kardex in pencil in the BLOOD TRANSFUISON ORDERS section. You would always put the date
of the Order and then transcribe just as it is written in the Physician Order.
Nutritional Care Orders
Communication with the Nutritional Care Department:
The procedure for ordering a new diet or a change or modification to an existing diet when paper charts are used requires the HUC to communicate the order by computer to the nutritional care department. The HUC chooses the correct patient from the unit census screen on the computer, selects the nutritional care department (dietary department) from the department ordering screen, then checks the box to order the specific diet from the options on the dietary screen, along with other items that apply (ie. Dietician consult). The HUC must communicate with the dietary department by computer or telephone when ordering a diet for a patient who has completed a procedure or test that requires him/her to be NPO. The patient’s allergies and intolerances must be communicated to the nutritional care department.
If the computer system is unavailable, the diet is ordered from the nutritional care department via a written downtime requisition, which is then filled out and faxed to the nutritional department. Once the computer systems are in working order, the HUC would have to manually enter the orders that were faxed
to the nutritional care department.
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All dietary information including orders for NPO, tube feedings, allergies, limit fluids, force fluids, and calorie counts must be sent to the dietary department so necessary adjustments will be made when the patient’s trays are prepared
Here is an example of a Dietary Requisition used when CPOE is not available:
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Standard diets consist of regular diet (DAT) and diets that vary in consistency or texture of foods, from CF to solids. A regular diet is planned to provide good nutrition and consists of all items in the four basic food groups. This diet is commonly ordered for patients who do not require restrictions or modifications of their diets. Standard Progression Diet
Clear Fluids, Clear Liquids: diet is used for patients who cannot tolerate solid foods, including those in whom an acute illness has been diagnosed and patients who have just had surgery. Clear fluids include broth, bouillon, tea, carbonated beverages, clear fruit juices, gelatin and popsicles. Full Fluids
: clear liquids with the addition of smooth-textured dairy products, custards, refined cooked cereals, vegetables and all fruit juices. This diet is usually ordered as a transitional step between a clear liquid diet and a soft diet.
Pureed
: most foods including meats, vegetables, and fruits can be processed to a puree consistency. No lumps or chunks, coarse textures, dried fruits, nits, seeds, or raw vegetables or fruits. Soft
: this diet is often used in the progression from a full liquid diet to a regular diet. It combines food considered non-irritating, easily digestible foods a with modified fiber content. Regular, DAT
: no restrictions unless specified.
*
All Standard Progression Diet orders are to be transcribed on the patient Kardex in pencil in the DIET section, you would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization for the above orders would be: K, Diet aware OR K, O/E Therapeutic Diets
A therapeutic diet is a specified diet ordered for specific conditions. Some common therapeutic diets are:
ADD Diet (attention deficit diet) – designed to provide adequate nutrition while avoiding certain food that
may exacerbate ADD
Bland Diet: designed to provide adequate nutrition s=during treatment of patients with inflammatory or ulcerative conditions of the esophagus, stomach or GI tract.
BRAT diet: this diet is commonly used as a short-term dietary treatment for diarrhea, gastroenteritis and some incidences of food poisoning.
Calories restricted diet: diet may be limited to a certain number of calories
Dysphagia diets: diets specified for patients who have difficulty swallowing
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*
All Therapeutic Diet orders are to be transcribed on the patient Kardex in pencil in the DIET section, you would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization for the above orders would be: K, Diet aware OR K, O/E Tube Feeds
: Also, a dietary order. Some common TF orders are:
Insert NG, verify placement and begin feeding of Isocal HN FS @ 40ml/hr/ Progress by 10 ml/hr q2h as tol to final rate or 90 ml/hr
*
All Tube Feed orders are to be transcribed on the patient Kardex in pencil in the DIET section, and there is a space for TF’s. You would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Symbolization for the above orders would be: K, Diet aware OR K, O/E Symbolization used for Transcribing a Dietary order:
Example 1:
CF x 12 hours, then FF x 12 hours, then DAT K, OE
You would symbolize K to acknowledge it has been transcribed onto the Kardex (in the Diet Section) and
OE (or i/c
) to acknowledge you have informed the nutritional department of the order via CPOE.
Example 2:
CF until dietician has seen to assess proper diet K, OE, Dietician aware
You would symbolize K to acknowledge it has been transcribed onto the Kardex (in the Diet Section), OE
(or i/c
) to acknowledge you have informed the nutritional department of the order via CPOE. You would also note Dietician aware to advise that you have called the dietician to let them know that there is an offer for them to assess the patient, and you would transcribe this onto the ‘consults’ section in the Kardex. (Most hospitals you still have to call the dietician to inform that there is an order for them)
RT, PT, OT, SLP, SW Orders
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Respiratory Treatments
40% O2 @ 4L/min NC Cont.: 4 L per minute of oxygen at 40% concentration is delivered continuously via nasal cannula
Incentive spirometry 15 min tid: this incentive spirometry treatment will be performed for 15 mins three times per day
Symbolization used on the physician order for the above examples would be: K
RT to see: respiratory therapist to see
Symbolization used on the physician order for the above example would be: K, RT Aware
*
All Respiratory Treatment orders are to be transcribed on the patient Kardex in pencil in the RESPIRATORY ORDERS section. You would always put the date of the Order and then transcribe just as
it is written in the Physician Order.
The Resp Support section is for Nursing Staff to fill out when the pt. is intubated:
Wound Care Orders
The wound care department or clinic specializes in treatment of nonhealing or slow healing wounds such as pressure sores or ulcers. *
All Wound Care orders are to be transcribed on the patient Kardex in pencil in the WOUND DRESSING
ORDERS section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order. If the order requests you consult a wound care nurse, you would need to add that to the CONSULTS section of the Kardex and notify the Wound Care Nurse or the order.
Symbolization used on the physician order for Wound care orders is: K, and WCN aware (if applicable)
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Physical Therapy Orders
PT to see: physiotherapist to see. PT to amb with walker as tol: the PT would assist the patient in using a walker for walking as tolerated
Symbolization used on the physician order for the above examples would be: K, PT Aware
Joint mobilization to lt. shoulder blade: the PT will mobilize the patient’s left shoulder
Symbolization used on the physician order for the above examples would be: K
*
All Physical Therapy orders are to be transcribed on the patient Kardex in pencil in the ACTIVITY section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order. If the order requests you consult a PT, you would need to add that to the CONSULTS section of the Kardex and notify the PT or the order.
Occupational Therapy Orders
OT for eval and treatment if needed daily: the physician is requesting the occupational therapist evaluate and treat if needed daily
OT to increase mobility: the order is requesting an occupational therapist assess the pt to increase their mobility. They may take the patient to do some stairs, or walking down the hallway as part of the assessment
Symbolization used on the physician order for the above examples would be: K, OT Aware
*
All Occupational Therapy orders are to be transcribed on the patient Kardex in pencil in the ACTIVITY section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order. If the order requests you consult a OT, you would need to add that to the CONSULTS section of the Kardex and notify the OT or the order.
Speech Therapy Order
SLP for swallowing assessment: the order is requesting the speech therapist is contacted to do a swallowing assessment on the patient
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Symbolization used on the physician order for the above examples would be: K, SLP Aware
*
All Speech Therapy orders are to be transcribed on the patient Kardex in pencil in the CONSULTS section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order
Social Worker Order
SW to see: the order is requesting the social worker is contacted to see the pt
Symbolization used on the physician order for the above examples would be: K, SW Aware
*
All Social Worker orders are to be transcribed on the patient Kardex in pencil in the CONSULTS section. You would always put the date of the Order and then transcribe just as it is written in the Physician Order
Disclaimer: if your hospital unit has CPOE for PT, OT, SLP, SW, RT etc., then your
symbolization would not be (blank) aware
, it would be OE
.
For Classroom purposes, we are using the (blank) aware
Miscellaneous Orders
It is impossible to pinpoint every miscellaneous order that a physician may write for a patient. Each physician has their own way of handling patient care and every hospital has different protocols. Here are some examples of miscellaneous orders you may come across.
Consultation:
Doctor’s orders for consultation may be expressed in writing on the doctor’s order sheets as followed:
Notify Dr Cynthia Avery from Valley Anesthesia to eval for CABG surg Symbolization for the above order would be
: K, Aware
ANA to see: anaesthesia to see
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Symbolization for the above order would be
: K, ANA Aware
*
All Consult orders are to be transcribed on the patient Kardex in pencil in the CONSULTS section, you would always put the date of the Order and then transcribe just as it is written in the Physician Order.
Temporary Absence/ Day Pass
Some patients in long term care settings are granted day passes or overnight passes. Also, some patients who are on psychiatric units, depending on their certification. May have pass for tomorrow from 0900-1500 May leave hospital from 1000-1200 hours today, have pt sign release. Symbolization for the above order would be
: K, Faxed
Orders must be faxed to pharmacy so that proper medications can be prepared for the duration of time away. *
All Temporary Absence/ Day Passes orders are to be transcribed on the patient Kardex in pencil in the MISC. NOTES section, you would always put the date of the Order and then transcribe just as it is written
in the Physician Order
When a patient has an order for a temporary absence, the HUC
:
1. Faxes/Scans the order to the pharmacy, so that any medications can be prepared for the patient while they are away
2. Cancel meals for the duration of the stay – either OE or via telephone to the dietary unit.
3. Cancel any scheduled hospital treatments/ procedures for the length of the absence. Departments should be contacted either via OE or via telephone.
4. Label/Print an Absence Release Form and place it on the chart. All patients who leave on a temporary absence or pass must sign in/sign out on the form. 5. Transcribe the order in the Kardex accordingly
When a patient has an order for ‘obtaining medical records’ from another site:
Often a physician will request a patient’s medical records from a site that they have been at and have had treatment, or a prior surgery.
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1) If the patient is within the same Health Authority
, all records can be viewed electronically, and no records should be requested by the Physician.
2) If the physician is requesting patient records from a facility within British Columbia from another Health Authority
, the HUC is to:
1. Call the receiving hospital and obtain the FAX number for the Medical Records Department
2. On Letterhead from the Sending site, request the patient’s medical records. Some HUC’s have preprinted FAX request forms that can be used, and some don’t, so you may need to make one up. It should look something like this: 3. Once the HUC has filled in a Fax request form appropriately, the request should be faxed to the correct number previously obtained.
4. The Faxed request should then be stamped with FAXED, and placed on the front of the patient’s chart, so that anyone who looks at the chart is aware that the records have been requested. Some facilities will send records in a few hours, and other facilities take a few days. 3) If the physician is requesting patient records from a facility outside of British Columbia (either in Canada or outside of Canada), the HUC is to take the following steps:
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1. Find out the exact facility the patient visited. This is important, for example, if the Dr writes an order to
get records from Ottawa Hospital, you would have to ask the RN or Dr to specify which site in Ottawa exactly.
2. Once the HUC knows which facility the records are to be obtained from, the HUC calls that facility and
requests the Health Records Department fax number.
- for out of country facilities, the HUC should be mindful of a) a language barrier and b) time zone. If the receiving site is in another country, and there is no one there that speaks English, the HUC may need to utilize an Interpreter. B) The time when records are requested should be business hours, typically 0800-
1600 hours. 3. Once a correct fax number is obtained, the HUC is to send a Fax Request to the site.
4. The Faxed request should then be stamped with FAXED, and placed on the front of the patient’s chart, so that anyone who looks at the chart is aware that the records have been requested. All request for Medical records should be transcribed onto the Kardex, under a ‘MISC NOTES’ section, and should be symbolized on the Physicians orders with K and requested
. When a patient has an order to schedule an appointment at a later date for a specialty appointment:
Sometimes a physician will write an order that looks something like:
Pt to be seen in Allergy Clinic within 2 weeks
Or
Pt to receive treatment at laser clinic at Valley Laser next week
This order is to be processed by the HUC.
1. The HUC would contact the Clinic/Facility in question and provide patient details as well as the request from the physician’s order.
2. The HUC would receive an appointment date/time for the patient to arrive at their appointment.
3. The HUC would write the order in the Kardex, and add the appt time/date in the Kardex.
4. Closer to the date, if the patient is still in hospital, the HUC would book transport for the patient. Some sites use privately owned transports like SNT or Medivan. Other sites would use BCEHS.
5. If the pt is discharged before their scheduled appointment time, the RN should instruct the patient of their appointment when he/she Discharges the patient.
All request future dates appointments should be transcribed onto the Kardex, under a ‘MISC NOTES’ section, and should be symbolized on the Physicians orders with K and booked
. Processing a Discharge, Transfer or Expiration Order
Patients may be transferred:
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1. to the nursing unit (transfer in)
2. From the nursing unit (transfer out)
3. Within the nursing unit (intra-unit transfer)
Transfers In and Out
: of the nursing unit may become necessary for the following reasons:
1. Patient’s who are ‘off service’ to their present nursing unit are transferred to the appropriate nursing unit when a bed become available.
2. The type of care required by a patient may have to be changed from the time the patient as admitted (example: medical patient now becomes a surgical patient)
Patients who are transferred either in or out are usually transported by wheelchair or stretcher, with all their personal belongings, their hospital chart and any records. A Nurse will inform the HUC when the patient is ready to be transferred and the HUC will book a Porter to take the patient to the new unit.
When a patient is to be transferred to another nursing unit, usually the physician will write an order to this
effect:
Pt to go to med unit when bed avail
HUC Responsibilities for a Transfer Out:
1. Collect the patient’s chart, patient’s old/thinned chart, Kardex and MAR shortly before the patient is to leave and place them ready to go for the RN with the patient.
2. When the RN or Charge Nurse have indicated the patient has left, in CPOE, transfer the patient to the correct destination. (this transfer note will inform Pharmacy, Dietary, SW, OT, PT..etc that the patient is no longer on your floor). 3. Add information to the ADT log book
4. Notify Housekeeping that the bed/room needs to be cleaned.
5. Erase the patients name and information from the Whiteboard if your unit is using one. HUC Responsibilities for a Transfer In:
When the nursing unit is to receive a patient from another nursing unit, you will be notified either by the Admitting Department or by the Charge Nurse with patient details.
1. Add information to the ADT log book
2. Ensure the assigned bed has been cleaned. If not, notify housekeeping. 3. When the patient arrives, greet the patient and direct the patient and their escorts to the assigned room
4. Check to see that the patient has been transferred into your Unit Census via CPOE. If not, call the sending unit clerk and ask her to put a transfer order into CPOE so you can now access the patient (if the patient is not electronically assigned to your unit, you will not have access to the patient).
5. Receive the patient’s chart, old chart, thinned chart, Kardex and MAR
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6. Relabel the patient’s chart with a label that has current up-to-date information. (the patient may have a different MRP now that he/she is on your unit, and will have a different room number)
7. Adjust the Kardex to reflect the patients current room number/unit/MRP.
8. Check the chart for any new orders that may still need to be processed. 9. Place the old or thinned chart in the designated place on your unit. 10. If your unit has a whiteboard, write the appropriate patient information on the white board.
11. Once the patient can be seen on your Unit Census, print off an updated Unit Census to work off of. Intra-Unit transfers: may be necessary for the following reasons
:
1. Request for a different level of accommodation that was available on admission
2. Request for a different bed in the same room (example, beside a window)
3. Isolation requirements
4. Comfort of the patient (noise, visitors, smell)
5. Efficiency of nursing care
6. To accommodate male/female patients by exchanging rooms
For an intra-unit transfer, the patient is usually moved in the bed along with the bedside table and personal belongings. The primary responsibilities of an Intra-Unit transfers are the relocating and renumbering of the patient records. When you have been advised of a patient transfer within the nursing unit:
1. Transfer the patient to the correct destination in CPOE
2. Add information to the ADT log book
3. Relabel the patient’s chart with a label that has current up-to-date information.
4. Adjust the Kardex to reflect the patients current room number 5. If your unit has a whiteboard, write the appropriate patient information on the white board
6. Notify housekeeping of the transfer.
Patient Expiration:
When a patient has expired, the HUC may be required to contact the Resident or MRP to examine the patient and pronounce death. Some patients may have a written order: RN to pronounce death, if the death
is inevitable and expected. It is the responsibility of the medical staff to inform the patient’s family. Phone calls from the immediate family of the patient should be referred to the medical staff and all other phone calls regarding the patient should be referred to the nursing staff.
HUC Responsibilities for a Death.
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1.Notify the Admitting Department via CPOE with a ‘notification of death’. This is just to inform admitting that the patient has expired in case they get calls from visitors/family.
2. Add information to the ADT log book
3. Obtain a ‘Death Pack’ for the patient, which includes pertinent records that need to be filled out. Most Unit Clerks have these ‘pre-made’ on the units. They contain the proper paperwork, mortuary tags and a Government Issued Death Certificate Form.
- make sure all the documents are labelled with the correct patient’s label
- make sure the death tags are labelled with the correct patient’s label
- prefill the date of death and time of death on any record where applicable. For example: The Certificate of Death attached, you would be able to fill out 1, 2, 4, 5, 6, 8 -in BLANK INK. 4. The RN will let the HUC know when the body is ready to be taken to the morgue. The HUC would then contact porter services and advise them of the transfer to the morgue.
5. The HUC will make sure the patient’s chart, old chart, thinned chart, Kardex, MAR are all ready to go – this must accompany the patient to the morgue with the body.
6. Notify housekeeping.
7. If your unit has a whiteboard, write the appropriate patient information on the white board
8. Notify the Admitting Department via CPOE that the patient has now been discharged to the morgue. 33
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Discharges
The discharge of a patient is always written by the physician on the Doctor’s Order Sheet. As well the physician will complete a Discharge Summary either at the time or later to indicate the final diagnoses. The physician will also indicate in the progress notes that the patient is to be discharged.
Routine discharges can be written either as a discharge for today or a discharge at a future date, usually tomorrow or a specified date.
HUC Responsibilities for discharges for future dates:
1. Process the Physician Order. A common discharge order will look like this: DC home Mar 7 in am
K, Faxed
- the HUC should fax this order to the Pharmacy, so that the Pharmacy can prepare the allotted medications for the duration of the patient’s stay and/or prepare any medications they may need to take home for a day or two (called discharge medications)
2. Record on the Kardex under MISC NOTES
HUC Responsibilities for discharges today:
1. When the patient has left the floor physically, notify Admitting via CPOE
2. Add information to the ADT log book
3. Notifying Housekeeping of the Discharge
4. Discard the Kardex in the shredding bin. (Reminder that the Kardex is not part of the patient’s permanent record)
5. When the RN is done charting on the patient, dismantle the cart. Place the records face down on your desk. Discard any records that are blank and not written on. Collect the patient’s old chart and thinned chart. Collect the patient’s MAR. Place all records in a ‘green envelope’ designated for Medical records and place the ‘Green Envelope’ in the designated spot for Medical Records to pick up. Discharge to another HealthCare Facility
Sometimes it is necessary for a patent to be transferred to another health care facility, hospital or nursing home. HUC Responsibilities for discharge of a patient to another facility:
1. If the patient is NOT being transferred to a facility within the same Health Authority, the HUC is to photocopy pertinent parts of the chart. This would include, recent Nursing Notes, Nursing records, Physician Porgress Notes, the MAR, any Consults. Place all photocopied records in a yellow envelope and label it ‘photocopied chart’. 35
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2. The HUC may be requested to book an Ambulance to transfer the patient. In order to do this, always have the pt information ready when you book the Ambulance, and know the hospital and unit the patient is going to. 3. When the Ambulance Service arrives at the unit, notify the RN and provide the Paramedics with the photocopied chart.
4. Notify Admitting via CPOE of the discharge
5. Add information to the ADT logbook
6. If your unit has a whiteboard, write the appropriate patient information on the white board
7. Notify Housekeeping of the transfer
8. When the RN is done charting on the patient, dismantle the cart. Place the records face down on your desk. Discard any records that are blank and not written on. Collect the patient’s old chart and thinned chart. Collect the patient’s MAR. Place all records in a ‘green envelope’ designated for Medical records and place the ‘Green Envelope’ in the designated spot for Medical Records to pick up. 36
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