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Medical Student Update

Medical Student Update. Douglas W. Coffey, RN, MSN Chief Nursing Officer December 10, 2007. WRITING ORDERS. Must be licensed to take a verbal order per Medical Staff Rules and Regs. May write an order and have it signed by Resident or Staff. All entries must be dated and timed.

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Medical Student Update

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  1. Medical Student Update Douglas W. Coffey, RN, MSN Chief Nursing Officer December 10, 2007

  2. WRITING ORDERS • Must be licensed to take a verbal order per Medical Staff Rules and Regs. • May write an order and have it signed by Resident or Staff. • All entries must be dated and timed. • All entries must be signed legibly. • Standard is that someone else must be able to decipher the signature.

  3. PROGRESS NOTES • All entries must be dated and timed. • Must be legible • Must be signed legibly. • Standard is that someone else must be able to decipher the signature.

  4. ABBREVIATIONS • List of do not use abbreviations on Order sheets, except those that have pre-printed orders. • Part of National Patient Safety Goals

  5. ABBREVIATIONS

  6. National Patient Safety Goals • Patient Identification - Always check armband before any procedure or test. • Communication – Always provide a report to an oncoming caregiver (SBAR). • Medications – All medications used must be properly labeled. • Reduce infections – Use of maximum sterile barriers in procedures.

  7. National Patient Safety Goals • Medication Reconciliation – reconcile medications upon admission, transfer and discharge. • Safety – Reduce falls • Patient Involvement – Include patient in discussions about care and condition.

  8. Questions

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