Documentation Questions

Hi -

I'm new to this board and was looking for a little advice and direction.

I work at a LTC facility (been there almost 10 yrs) -- during one of my shifts a physician taking care of one of my patients wrote an order on our 'telephone order' sheet instead of writing it on the 'written orders' sheet. She included the patient's name, order, date and her signature. She neglected to fill out the facility name and address, her full name and phone #. I treated the order as I would any written order and transcribed it into the MAR.

My supervisor called this incident to my attention and told me that I should have filled out the facility name and doctor's information on the form. I explained to her that I was taught not to write on a physician's written order (other than noting it was transcribed). She told me I MUST fill out this information if this is ever to happen again.

Am I responsible for filling out this information?? Wouldn't I be held liable in a court of law for adding to the written order?? The physician could deny that it was her handwriting and perhaps even deny that she even wrote the order??


Second Question:

Does anyone abbreviate -- 'Leave open to air' as LOTA -- my supervisor says this is unacceptable and the whole phase should be written out. I have used this abbrev for years.

I have been written up b/c of these 2 incidents and am now being told to take a documentation class!!

Any thoughts are appreciated.
Also, does anyone know where I can find literature on this.

THANK YOU!
In the example given, yes you could write out the indentifying data because you are not adding to the actual order and that is what you would do on a regular TO. Quite often nurses write out orders for the doctor's signature when it is known that the doctor is likely to sign off on the particular order. In that case, the order is not transcribed until signed. For several years now some employers have become more stringent in the use of abbreviations. Not wanting to go through the trouble of distinguishing between accepted and non-accepted abbreviations, I write out everything. It was a hard habit to break in the beginning, but I am used to writing everything out now.

Quote from tripletmommaHi -I'm new to this board and was looking for a little advice and direction.I work at a LTC facility (been there almost 10 yrs) -- during one of my shifts a physician taking care of one of my patients wrote an order on our 'telephone order' sheet instead of writing it on the 'written orders' sheet. She included the patient's name, order, date and her signature. She neglected to fill out the facility name and address, her full name and phone #. I treated the order as I would any written order and transcribed it into the MAR. My supervisor called this incident to my attention and told me that I should have filled out the facility name and doctor's information on the form. I explained to her that I was taught not to write on a physician's written order (other than noting it was transcribed). She told me I MUST fill out this information if this is ever to happen again.Am I responsible for filling out this information?? Wouldn't I be held liable in a court of law for adding to the written order?? The physician could deny that it was her handwriting and perhaps even deny that she even wrote the order??

The list of accepted JCAHO abbreviations and non-accepted abbreviations can be found on their website.

tripletmomma, Unquestionably, every hospital has their own regulation regarding abbreviations when charting. Moreover, this has been the most costly,controversy and criticized subject in all hospitals and pharmacies, because so many abbreviations are made up by medical staff or are not recognized by the institution. Therefore, If I was in your situation I would follow the rules of universally known abbreviations accepted by your hospital. In addition, when there's a doubt its' better to write it out than to make a costly mistake. Furthermore, on the subject of filling out the physician's name etc... follow your hospital guide lines, if they want you to fill it out do so, but place your initials next to it, just in case the chart ever goes to trial; trust me when I say that for a little while your charting will be under scrutiny, so it's best to adhered to the rules of your hospital. Later on, when your evaluation comes around they can't held it against you, I always said don't give anyone ammunition to use against you. Best of luck in all of your future endeavors

You should refer to your facility policy & procedure for acceptable abbreviations. And, no, I have never heard of LOTA. We have a big problem where I work with nurses just making up abbreviations. Makes it hard for others that go behind them to provide care (continuity)

I've never seen different oder forms in LTC. Most of our orders are telephone orders. Yes, you could fill in the demographic type of info on an order. If you felt funny about it you could call the doc, tell them you needed to do that and make a nurses note to cya. We use one form for all orders. Most docs won't fill our anything but the actual order and their signature when they hand write the orders. When you go to fax the order to pharm they are going to need the facilty name and the pt name. As far as the abbreviations....I'll bet your facilty has a list of acceptable abreviations. Check into it. why would they be writting you up all of the sudden for these things if you've used it for years at the same place and they've never said anything before? At the very least, they should give you a warning and a list of acceptable abbreviations for your facility.

for the most part, abbreviations are not a good thing. Too many ways to misinterpret them. As for the order, adding that stuff is not changing the order. Would be better to "educate" the MD of course to do it right the first time and save other people the trouble. Seems like a lot to write, though. If the MD has privileges why would the address, etc be needed with each order?

You are not adding to the order by filling in the facility name. JCAHO is scrutinizing all orders for completeness now, so I suspect this is why you heard about this one. It is a matter for the doctors to be educated and made to fill orders out correctly, but this will never happen, so once again it falls back on the nurse. I've never heard of LOTA. Another hot topic with JCAHO is abbreviations so most places have a policy about what is appropriate. When in doubt spell it out.

Things change all the time, taking the class is a great suggestion, but this information can be found on the web also. As for the abbreviation I suggest " better safe than sorry" write it out, if the facility doesn't want you to use it, then don't...