Resident Documentation, Orders And

Resident Documentation, Orders and

Prescription Writing

TABLE OF CONTENTS

Documentation and Order Writing on Teaching Services 2

Verbal Orders for all Teaching Patients 3

Resident Prescription Writing 4

Medication Prescribing Guidelines 5

Documentation and Order Writing

On Teaching Services

Policy: In admitting patients to the Medical Teaching Services, including the critical care units, the attending physician should delegate order writing to the resident physicians assigned or covering the patient whenever possible. Residents also per their respective job duties document admissions, history and physicals, progress notes and discharge summaries.

Procedure: Residents will perform a complete initial history and physical on all teaching admissions and review the assessment and plan with a more senior resident and the attending physician. Initial orders will be written by the residents. Recommendations of the attending and consultants as noted in the records or transmitted verbally should be discussed and acted upon without delay. Residents must include their beeper number with all signatures on the chart such as orders, history and physicals, progress notes and all other documents requiring signatures.

Attendings who wish orders to be implemented urgently should page the responsible or covering resident to write them. If the resident cannot comply within a short period of time (15 minutes), and if urgent, the attending physician may write the orders and include an order to call the resident to review them and the associated progress note as soon as possible.

It is expected that there will be a few brief initial orders written by the attending or the emergency department physician to initiate the referral to the teaching service. It is further expected that on occasions when urgent orders, or highly specialized orders (i.e., chemotherapy), or orders related to a specific invasive procedure by a consultant, that the attending or consulting physician may write some orders. However, under most circumstances, residents should write the teaching patients’ orders based on written or verbal interactions with the attending and consulting staff or supervising senior resident.

Verbal Orders for All Teaching Patients

Verbal orders shall:

1. Only be given for emergent or urgent indications by a resident when another patient care emergency or urgency precludes immediate access to the patient and the chart.

2. BE SIGNED AND DATED BY THE NEXT MORNING. All residents on an inpatient service rotation must log onto Last Word the first thing everyday and sign all verbal orders.

3. Only be for patients known to be on the teaching service - the resident must verify this prior to giving any verbal order.

4. It is the responsibility of the resident who issued the verbal order to insure it is signed and dated by the next morning.

5. The appropriate on-duty resident each day will check all teaching charts on the services they cover to sign and date all remaining unsigned verbal orders.

6. Residents with two or more verbal orders not signed/dated will be asked to appear before the Graduate Medical Education Committee.

7. Repeated failure to comply with this new policy may result in corrective action including suspension, probation, or termination.

Cc: Medical Staff Office

Nursing Administration

Nursing Stations

Attending Staff

Resident Prescription Writing

1. Residents must follow the Oakwood policy entitled “Medication Prescribing Guidelines” (attached).

2. Residents may only write prescriptions for patients they have evaluated in clinic or during hospital encounters that are documented in the medical record.

3. All residents will be provided a pharmacy stamp for all outpatient prescriptions and inpatient orders at the beginning of their residency. If the stamp is lost, stolen, or broken residents will be charged a $10 fee for replacement. This fee may not come from the resident’s benefit allowance. It is imperative that you use this stamp on all outpatient prescriptions. You must also sign the prescription. The stamp is not a replacement for your signature. If you do not utilize this stamp, or have the information on the stamp in legible writing on all your prescriptions, the DEA can refuse to give you, or can revoke, your DEA license.

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Effective Date: 9/18/00

Revised: April 2004