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Processing Patient Care Orders (6.29)

Processing Patient Care Orders (6.29) - Policies, Administrative, UWHC, Department Specific, Nursing Administrative, Clinical Nursing

6.29

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
September 21,
2015

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 6.29

Original
Revision

Page
1
of 6

Title: Processing Patient Care Orders

I. PURPOSE

To provide consistent and accurate procedures for processing patient care orders. To
communicate and facilitate the implementation of the plan of care for the patient.
Please also refer to UWHC Hospital Administrative Policy 8.16, Patient Care Orders,
and Nursing Patient Care Policy 10.19, Medication Administration Using Scanning
Technology.

II. EQUIPMENT

UWHC forms or requisitions for service, supplies or equipment not otherwise
contained in the electronic health record.

III. POLICY

All orders are reviewed, acknowledged, and / or verified by a registered nurse and
other disciplines as appropriate and within their scope of practice.

IV. PROCEDURE

A. General Considerations For All Orders (Please refer to UWHC Hospital
Administrative Policy 8.16, Patient Care Orders.)
1. Patient care orders will be entered into the electronic health record
(EHR).
2. Orders are required for diet, activity, medications, treatments,
diagnostic studies, consultations and miscellaneous orders.
3. All orders are to include the date and time the order was submitted, the
order, and the ordering clinician.
4. Discharge orders must be submitted using the Discharge Navigator in
the EHR.
5. The provider should notify the nurse verbally if a STAT order is
submitted. If the health unit coordinator is alerted, he/she must notify a
registered nurse immediately; if it is a STAT medication order, the
pharmacist also must be alerted, by the ordering provider.
6. Whenever there is any uncertainty as to whether an order no longer
applies, the nurse and provider should collaboratively review the order.
7. Any question concerning an order should be referred to the provider
submitting the order, or in his/her absence, the physician or APP

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responsible for the patient's care. If the question cannot be resolved, refer
to successively higher nursing and medical levels.
8. It is imperative that the correct ordering provider name be included
with all orders. The correct ordering provider name ensures that reports
and test results are communicated to the correct provider.
B. Patient Status Orders
1. The appropriate patient status is important for several reasons, including to
ensure appropriate claim submission. Guidelines for determining the
appropriate status differ by payer. Coordinated Care RN Case Managers
assist providers in determining the appropriate status.
a. Provider enters an admission status order. If no admission status
order is entered, the status is outpatient.
b. For elective inpatient surgeries, the inpatient status order must be
entered prior to the start of surgery.
c. For direct admissions, the inpatient status order should be entered
as soon as possible after the patient arrives.
d. For admissions from the emergency department, the status order
should be entered as soon as possible after the decision to admit
has been made.
e. The patient class needs to match the patient status order. Patient
class is managed in the EHR Event Management.
f. The admission status may change during admission, particularly
during the first two midnights. Unit staff help ensure that the
patient class matches the respective admission status order
throughout admission.
C. Medication And Parenteral Fluid Orders
1. Initiation of medication orders
a. Provider includes appropriate information for a medication order in
the EHRaccording to Policy 8.16, Patient Care Orders.
b. Pharmacist verifies the medication in the verification queue.
c. Registered Nurse verifies the medication in the medication
administration record (MAR).
d. Respiratory Therapist verifies medications administered by the
Respiratory Therapists.
e. Radiology Technicians verify medications they administer.
2. Discontinuation of medication orders
a. Provider discontinues order in the EHR.
b. Pharmacist discontinues the medication in the verification queue.
c. Registered nurse verifies discontinued medication order in the
MAR.
d. Respiratory Therapist verifies discontinued medications
administered by Respiratory Therapy.
D. Orders For Blood And Blood Components (See UWHC Hospital Administrative
Policy 8.12, Blood and Blood Component Transfusion [Requiring Pre-
Transfusion Testing])
1. All blood products except albumin are ordered through blood bank order
entry functions. Albumin is ordered through pharmacy.
2. The following information must be specified in the orders for blood/blood
components:

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a. Reason for transfusion (indication code)
b. Blood or blood component to be transfused and special product
requirements such as CMV negative, irradiated, etc.
c. Numbers of units or volume in milliliters to be transfused
d. Time transfusion is to be initiated
e. Flow rate
3. An order must be entered for the blood/blood components and a separate
order is entered to transfuse the blood/blood components.
E. Nursing Communication Orders
1. Where orders do not already exist, Nursing Communication orders are
entered in the EHR.
2. Nursing Communication orders should not be used to discontinue an
existing order, rather the existing order should be modified or
discontinued as appropriate to the patient’s needs.
F. Diet And Nutrition Orders
1. The admitting diet order is NPO until a provider writes a diet order. Diet
orders include tube feedings (TF), NPO, and parenteral nutrition (PN).
2. Provider enters diet and nutrition orders into the EHR.
3. A diet order specifying food and/or nutrition products must be ordered
before any food is administered to the patient. (See UWHC Hospital
Administrative Policy 3.10, Dietetic Orders.)
4. Provider enters additional information and orders into the EHR specific to
each patient, such as food allergies, fluid restrictions, force fluids,
nourishment orders and supplemental feedings. Clinical Nutritionists may
modify these orders if the modification is intended to clarify the original
order or if the modification is intended to accommodate patient
preferences or ensure the patient is meeting their macronutrient needs (i.e.
adding orders “Patient is Approved for Additional Menu Item” and/or
“Beneprotein” or “ProSource”) while honoring the limitations of the
original diet order. The order will be entered as “Per previous order.”
5. Room Service staff verify trays match the diet order and record meal
delivery time using a diet list printed on the unit.
6. Several patient care protocols, approved by the Medical Board, enable the
physician to delegate limited order writing authority to inpatient Clinical
Nutritionists for UWHC and AFCH for the following tasks (refer to
UWHC Inpatient Protocols on U Connect.
7. To enact any of the protocols, the physician will order a Consult to
Nutrition. The Consult Nutrition screen has been revised so that the
physician must first select a reason for consult. When delegating, select
“assessment.” The physician may then select whichever of the above
action(s) he/she chooses to delegate. The delegation will remain in effect
through the current admission, unless the physician discontinues the
consult.
G. Activity Orders
1. Provider indicates type of activity ordered for the patient in the EHR.
2. Registered Nurse and/or appropriate therapists coordinate ordering
equipment as necessary to carry out activity order.
H. Orders For Consult Services

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Clinicians are responsible for providing all necessary information in an
order for a consultation, including name of requested department and
service, reason for consult and any other salient points. Clinicians must
follow specific order instructions regarding communication with the
consult service (ex. phone call, paging).
I. Orders For Radiology Services (For diagnostic tests requiring preparation of the
patient, see Nursing Guide to Radiology Procedures on U-Connect.)
1. The following information must be specified in the EHR for radiology
services:
a. Purpose of test
b. Scheduling guidelines
c. Pre- and post-procedure care.
2. Provider enters radiology orders into the EHR.
3. The health unit coordinator or nurse will indicate the transport method as
requested by Radiology if it is not already indicated If a test or procedure
is ordered STAT or ASAP, the unit must notify Radiology by phone as
well as entering the request in the EHR. If the STAT or ASAP procedure
is after hours the provider must contact the radiology resident on call.
4. If test or procedure is ordered for a future date, the Priority is entered as
Routine and the date the test or procedure is to be done is entered in the
"Starting" field.
5. A provider order is required to request reading of outside films. Use the
OUTSIDE FILM READ order in the EHR. Films should be sent to the
Radiology Department.
J. Orders For Laboratory Services
1. Every attempt to consolidate laboratory orders requiring blood collection
should be made to reduce the number of blood collection events per
patient.
2. For inpatients, blood is the only specimen type collected by the
Phlebotomy service. Phlebotomy staff cannot collect specimens from
venous access devices (VAD Phlebotomy rounding is available between
0500 and 2300 for non-ICU units or those floors designated as nurse
collect only.
3. If the blood is to be obtained by lab personnel, ideally the order must be
entered into the EHR at least 10 minutes before the start of the hour for the
next phlebotomy collection round. Use the following options in the Order
Composer:
a. Next AM - This will put the order in the next 0500 to 0900
collection group. Specimens will be collected by phlebotomists
during that period of time. Do NOT add a specific time as this will
move the collection to a Nurse Collect and orders will not be
combined.
b. Next Draw - This puts the order into the next phlebotomy round
for the nursing unit. Orders are automatically released to the lab
system for a particular round 30 minutes prior to the hour and until
59 minutes after that hour.
c. Orders placed for every 4, 6, 8, etc hours will be scheduled for
phlebotomy during the normal hours of operation.

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4. If the specimen will be obtained by unit personnel, lab requisition forms
and patient labels should be generated from the EHR. Specimen labeling
must be completed according to Clinical Laboratories Policy 1502.5.06,
Acceptance Policy for Specimen Identification.
5. If specimens have been scheduled for the phlebotomy team and the nurse
needs to collect, collect specimens, attach unit generated patient labels and
submit specimens with the Phlebotomy Collect Orders that are Drawn by
Unit form. The lab will complete processing of the orders. Please ensure
the second half of the form is placed in the phlebotomy binder, so the
phlebotomist is aware the blood was collected.
6. Blood cultures that are to be drawn by lab personnel require an order. The
phlebotomist on rounds receives electronic notification of the Blood
Culture order and will give the unit staff a card identifying the patient
needing the blood culture. The unit staff must notify the Blood Culture
Phlebotomist via pager 6700 (or call 219-5963 only if paging is down) and
add instructions to the card if necessary. The card is placed in the
phlebotomy binder for pickup by the Blood Culture phlebotomist. The
Blood Culture phlebotomist will report to the unit as soon as possible for
collection of the culture and all pending bloods on the patient. Please
NOTE: Blood cultures collected by Phlebotomy services cannot be off a
venous access device and will be collected via venipuncture.
7. If the ordering user cannot find a test on the preference list or the facility
preference list then the Miscellaneous Lab test order can be used. It may
be helpful to first call Lab Client Service at 263-7060 to ask if the test is
available and listed under another name. If the Miscellaneous Lab test is
used, the ordering provider must use one Miscellaneous Lab Test order for
each test requested. Multiple test requests cannot be contained in one
Miscellaneous Test order.
8. For STAT laboratory studies, write STAT in large red letters on the
appropriate requisition. Lab personnel will draw STAT labs if they are on
the unit at the time the lab needs to be drawn, however, unit personnel are
responsible for transporting the specimen to the lab.
9. Timed specimens (Specific Time – RN Collect) should not be transferred
to Lab collect unless the phlebotomist is on the unit and has confirmed
blood collection from the patient will be completed at the correct time.
10. For non-blood specimens, generate lab requisition form and patient label
from the EHR. Specimen labeling must be completed according to
Clinical Laboratories Policy 1502.5.06, Acceptance Policy for Specimen
Identification.
11. When requesting lab tests to be performed on specimens that have already
been received in the lab:
a. In the EHR, select and open the test to add-on to the existing
specimen.
b. Change the order frequency to Add-On and answer the add-on
related questions.
c. Repeat the process for any additional lab tests requested. The
ordering provider must enter a separate order for each add-on test
desired.
K. Cardiopulmonary Resuscitation (CPR) Orders

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1. The attending physician must sign orders for No CPR or Limited CPR
code status. Residents may submit these code status orders as verbal
orders for attending physician cosignature within 24 hours. (See UWHC
Hospital Administrative Policy 8.23, Do Not Resuscitate/No CPR Order.)
L. Isolation Orders
1. Orders for isolation status will be entered into the EHR. (See UWHC
Hospital Administrative Policy 13.07, Standard Precautions &
Transmission-based Precautions (Isolation) for Inpatient Settings.)
M. Pre-Operative Orders
1. At the time the preoperative orders are acknowledged, a preoperative
checklist should be initiated.
N. Discharge Orders
1. Orders for discharge medications and discharge orders should be
submitted by the provider in the EHR.
2. After counseling the patient and giving the patient prescriptions for
discharge medications, the pharmacist will document in the EHR that the
patient received prescriptions and instructions.
3. The nurse or health unit coordinator will contact other departments as
indicated for services, tests, equipment or instructions.
4. The nurse or health unit coordinator will make appointments with UW
Health Clinics or schedule UWHC/AFCH readmission as indicated.
Appointments scheduled at UW Health Clinics will display on the After
Hospital Care Plan provided to the patient. For appointments requested
with non-UW Health Clinics, the nurse or Health Unit Coordinator will
enter that information in Appointments Scheduled at Outside Facility
using the Add/Edit comments.
5. The Registered Nurse will review the discharge order with the patient and
family.
O. Orders During the EHR Downtime
1. Refer to UWHC Hospital Administrative Policy 6.37, Inpatient Health
Link Downtime & Recovery, for managing orders during downtime.

V. UWHC CROSS REFERENCES

A. Clinical Laboratories Policy 1502.5.06, Acceptance Policy for Specimen
Identification
B. Hospital Administrative Policy 1.03, Patient Status and Observation Patient
Management
C. Hospital Administrative Policy 3.10, Dietetic Orders
D. Hospital Administrative Policy 6.37, Inpatient Health Link Downtime &
Recovery
E. Hospital Administrative Policy 8.12, Blood and Blood Component Transfusion
(Requiring Pre-Transfusion Testing)
F. Hospital Administrative Policy 8.16, Patient Care Orders
G. Hospital Administrative Policy 8.23, Do Not Resuscitate/No CPR Order
H. Hospital Administrative Policy 13.07, Standard Precautions & Transmission-
based Precautions (Isolation) for Inpatient Settings
I. Inpatient Protocol 46, Clinical Nutrition Initiation & Management of Tube
Feedings

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J. Inpatient Protocol 53, Management of Diet for the Treatment of Dysphagia
K. Inpatient Protocol 54, Clinical Nutrition Authority to Write Diet & Nourishment
Orders
L. Nursing Patient Care Policy 10.19, Medication Administration Using Barcode
Scanning Technology
M. Nursing Patient Care Policy 14.12, Discharge of the Inpatient
N. Nursing Patient Care Policy 14.17, Transfer of the Patient
O. Nursing Patient Care Policy 14.19, Preparing a Continuity of Care Referral for an
Inpatient Discharge

VI. REVIEWED BY

Director, Lab Patient Services Director, Clinical Nutrition Services
Director, Coordinated Care
Manager, Pharmacy
Manager, Radiology
Director, Nursing Informatics
Nursing Patient Care Policy and Procedure Committee, September 2015

SIGNED BY

Beth Houlahan, DNP, RN
Senior Vice President Patient Care Services, Chief Nursing Officer