Tag: Doctor Orders

Articles about properly managing and executing doctor orders in health care.

Properly entering doctor orders

You are in with a patient with whom you believe will benefit from a treatment/medication. You call the provider who either goes with the recommendation you made as part of the SBAR (situation, background, assessment, nursing recommendation) or otherwise adjusted it to better fit the situation. Most EMR (electronic medical record systems) now requires you to enter a doctor (provider) order. For visiting staff, most EMR systems will send an electronic communication to the doctor to “sign” the verbal order over the next 24 hours (some systems, the next business day). Can you imagine how many orders the provider must sign in a day? How do you protect your patient and your nursing license in the written documentation of the doctor’s order you enter into whatever system you are using?
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