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Policies,Clinical,UW Health Clinical,Medical Records and Communication,Patient Care Orders

Patient Care Orders (3.4.2)

Patient Care Orders (3.4.2) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Patient Care Orders

3.4.2


UW HEALTH CLINICAL POLICY 1
Policy Title: Patient Care Orders
Policy Number: 3.4.2
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: November 30, 2017

I. PURPOSE

To establish a safe process of communicating directives for patient care.

II. DEFINITIONS

A. Medication: Any prescription medications, sample medications, herbal remedies, vitamins, nutraceuticals,
vaccines, or over-the-counter drugs; diagnostic and contrast agents used on or administered to persons to
diagnose, treat, or prevent disease or other abnormal conditions; radioactive medications, respiratory
therapy treatments, parenteral nutrition, blood derivatives, and intravenous solutions (plain, with electrolytes
and/or drugs); and any product designated by the Food and Drug Administration (FDA) as a drug. This
definition of medication does not include enteral nutrition solutions (which are considered food products),
oxygen, and other medical gases.
B. Co-signature (cosign): A cosign represents a health care provider’s acknowledgement of work performed for
a patient on a provider’s behalf or under a provider’s supervision. In Health Link, cosign messages are
electronically routed to providers’ InBasket “Cosign” folders.
C. Advanced Practice Provider (APP): Advanced Practice Nurse who holds WI APNP Certification and
Physician Assistant (PA).
D. Provider: For the purposes of this policy this term describes a physician, APP, or GME Trainee authorized to
place orders at UW Health.
E. Order Mode: Tag on an order that identifies a person’s authority to sign those orders. Order Modes include:
i. Protocol/Policy without cosign: “Protocol” refers to delegation protocols (approved by the Medical
Board) that allow delegation from an ordering provider to staff beyond their normal scope of
practice (refer to UW Health Clinical Policy #1.2.8, UW Health Patient Care Delegation Protocols).
ii. Cosign Required Protocol/Policy: “Protocol” refers to delegation protocols (approved by the Medical
Board) that allow delegation from an ordering provider to staff beyond their normal scope of
practice. The Delegation Protocol will state that the order requires a cosign.
iii. Verbal, read back, confirmed: Verbal order mode should not be used for convenience, but should
be used in a HIPAA compliant manner in cases where a delay in patient care could adversely affect
the patient.
iv. Per Previous Order: Orders entered by a user based on direction from a previous (signed) order.
v. Transcribed: Transcribed from a signed order, therefore does not require co-signature.
vi. Standard: Default order signing/cosigning behavior. For providers all orders are signed and do not
require co-signature. For all other personnel orders may or may not be automatically routed for co-
signature based on licensure and scope of practice.

III. POLICY ELEMENTS

A. Only patient care orders given by a person authorized in accordance with this policy will be accepted and
executed. The procedures in this policy will be followed when accepting and documenting patient care
orders.
B. Orders should not be acted on unless they are complete, legible, and clear. Any questions arising from an
order, including but not limited to the interpretation of an illegible order, an incomplete order, an unusual
dose, or a question of allergy, adverse reaction or incompatibility should be referred to the ordering provider
(or other order writer if within the scope of the delegation protocol) responsible for the patient's care. The
order should not be implemented until the question is resolved.
C. The electronic medical record (EMR) should be used to enter orders in all situations where available.
D. Implementation of Health Link. Any provisions of this policy related to paper records and forms shall be
superseded by the applicable electronic processes in all areas where such electronic process have been
implemented. Any signature required by this policy can be accomplished electronically or by the steps
specified in other approved polices and protocols.
E. All orders must be dated, timed, and authenticated either in written or electronic form.
F. Use of secure or unsecured text messaging for patient care orders is not acceptable.





UW HEALTH CLINICAL POLICY 2
Policy Title: Patient Care Orders
Policy Number: 3.4.2

IV. PROCEDURE

A. The following persons are authorized to place orders within the scope indicated.
i. All orders:
a. A provider acting within the scope of professional practice and within the scope of their
professional privileges at Joint Commission accredited sites.
b. A graduate medical education (GME) trainee approved by or formally affiliated with UW
Health within the scope of the training program.
c. A non-provider working within their scope of practice.
d. Physical therapists employed by UW Health that have completed an approved Outpatient
Rehab orientation and training program may order outpatient physical therapy within the
scope of professional practice, except in cases that are covered by worker’s
compensation. Physical therapists employed by UW Health may also order x-rays within
the scope of practice and department policy, provided that applicable licensing regulations
authorizing the practice have become effective.
ii. Orders pursuant to delegation.
a. Any staff member may place an order within the scope of delegation as authorized by a
policy or protocol approved by the Medical Board (see UW Health Clinical Policy #1.2.8,
UW Health Patient Care Delegation Protocols
iii. Orders written by students:
a. Unless prohibited by State Law, Students may prepare orders within the scope of their
training program, however those orders shall not be implemented until dated, timed, and
authenticated either in written or electronic form by a provider,
iv. Hospital-based outpatient services may be ordered by a non-privileged individual who meets the
following conditions:
a. Is responsible for the care of the patient.
b. Is licensed in the State where he or she provides care to the patient.
c. Is acting within his or her scope of practice under State Law.
d. Exceptions may include, but are not limited to, antimicrobials, chemotherapy and dialysis
as outlined in UW Health Clinical Policy #6.1.1, Chemotherapy Process: Informed
Consent, Ordering, Verification, Administration, Documentation, and Patient/Family
Education, Department of Pharmacy Policy #13.19, Infectious Diseases Section Approval
of Orders for Restricted Antimicrobial Agents, and Hemodialysis Department Policy #1.0
Scope of Services delivered by UWHC Inpatient Hemodialysis Department. Additional
exceptions may be determined and maintained by individual departments.
B. Safe Order Writing Practices.
i. Verbal Orders.
a. General.
1. Verbal orders should be minimized. Verbal orders should be used to meet the
care needs of the patient when it is impossible or impractical for the ordering
practitioner to place the order. Verbal orders are not to be used for convenience.
2. Verbal orders may be given only by providers.
3. Staff receiving verbal orders must immediately write them down, read them back,
and receive confirmation of accuracy from the individual who gave the order. In
areas where Health Link is used to manage orders, staff receiving verbal orders
should complete entry of the orders while the provider is present in person or on
the telephone whenever possible.
4. All verbal orders must be signed or cosigned by an ordering provider prior to
signoff or discharge of the patient in the ED and procedure areas, and within 48
hours on inpatient units. In ambulatory areas, verbal orders must be signed or
cosigned by an ordering provider within 48 hours, excluding weekends, when
these areas are closed. This does not apply to prescriptions telephoned to
community pharmacies. Physician assistants and advance practice nurse
prescribers may only sign or cosign their own verbal orders for medications and
biologics.
5. Verbal orders may not be accepted for the initiation of chemotherapy nor
intrathecal medication orders of any type. Chemotherapy verbal orders for
changes to existing chemotherapy orders may be accepted only under limited
circumstances as outlined in UW Health Clinical Policy #6.1.1, Chemotherapy



UW HEALTH CLINICAL POLICY 3
Policy Title: Patient Care Orders
Policy Number: 3.4.2

Process: Informed Consent, Ordering, Verification, Administration,
Documentation, and Patient/Family Education.
b. Staff authorized to receive and record verbal orders within their respective scope of
practice:
1. Registered Nurse
2. Pharmacist
3. Respiratory Therapist
4. Allied Health Personnel (physical therapist, speech therapist, occupational
therapist, registered dietitian nutritionist, and other authorized personnel)
5. Medical Assistant (MA) in clinics or Ophthalmic Technicians in Ophthalmology
Clinics
6. Nuclear medicine technologists
7. Sonographers
C. Elements of an Order.
i. All orders
a. Patient’s first and last name
b. Patients date of birth or medical record number
c. Must contain all required elements as defined by policy and as required by Health Link
ii. Laboratory Orders
a. Laboratory test orders must include the following:
1. Patient's first and last name
2. Patient's sex
3. Patient's age or date of birth
4. Contact information of the authorized person requesting the test, and if different,
the individual responsible for using the test results, in order to report routine and
critical test values
5. Name of the test(s) ordered
6. Date and, if appropriate, time the specimen was collected
7. The specimen source, when appropriate
8. For Pap smears, the date of the patient’s last menstrual period, and indication of
whether the patient had a previous abnormal report, treatment, or biopsy.
9. Additional information required by the laboratory to support accurate test
interpretation and reporting of results, such as race, ethnicity, or family history
iii. Medication orders
a. A diagnosis, condition, or indication for use exists for each medication ordered. This
information can be anywhere in the medical record and need not be on the order itself. For
example, it might be part of the medical history. As needed (PRN) orders and
antimicrobial orders should include an indication, and if they are received without an
indication then the pharmacist or nurse will confirm the indication.
b. The following information about the patient is accessible to provider and staff who
participate in the management of the patient's medications and is maintained within in the
medical record.
1. Name of the patient
2. Age
3. Sex
4. Diagnoses
5. Allergies and/or Sensitivities
6. Current medications list
7. Height and weight in kilograms or grams (when necessary)
8. Pregnancy and lactation information (when necessary)
9. Laboratory results (when necessary)
c. Date and time of the order
d. Unabbreviated drug name (generic preferred; trade or brand names may be listed in
parentheses).
e. Dose and dosing units. Doses are written using metric or drug activity units
f. Dose calculation requirements, when applicable.
g. Exact strength or concentration, when applicable
h. Route of administration.
i. Frequency.



UW HEALTH CLINICAL POLICY 4
Policy Title: Patient Care Orders
Policy Number: 3.4.2

j. Quantity and/or duration (start date/end date if applicable).
k. Special instructions for use if applicable.
l. Signature and title; pager number recommended.
m. Specify rate when ordering IV solutions (To keep open “TKO” is not acceptable).
n. Specify both anion and cation (the entire salt) when ordering electrolytes.
o. Only use abbreviations listed in UW Health administrative policy #6.18, UW Health
Approved Abbreviation List. Orders shall be verified with the ordering provider when one
of the following error prone abbreviations is used: u, IU, cc, qd, qod, q, tiw, lack of a
leading zero, use of a trailing zero, MS or MSO4, MgSO4.
p. Ambiguous, summary, or blanket orders such as "continue pre-op meds," "resume
previous medications," "take as directed" and "titrate to comfort" are not allowed.
q. Open ended orders such as "titrate to response" are not acceptable. Orders should
specify an appropriate dose range and frequency suitable for the drug, patient
characteristics and situation. Open-ended orders without an upper limit are not
acceptable. To be an acceptable titration order, the order should include the following:
1. An initial starting dose (e.g., esmolol 50mcg/kg/min)
2. The amount by which to increase or decrease the dose (titrate by 50mcg)
3. A specified interval (every 15 minutes)
4. A desired objective response (to maintain a SBP between 120 and 155mmHg)
5. A maximum dose (to a maximum dose of 300mcg/kg/min)
r. Orders to temporarily hold a scheduled medication for inpatients should use the “Hold
Medication Communication Order” and must specify the number of doses medication
name, date, time and reason for holding. Orders to hold a medication indefinitely will be
interpreted as discontinuation of the medication.
s. Conditional orders are also not acceptable (e.g., when hematocrit > X and INR=Y, start
heparin at Z units/hr and increase until ACT goal met; or if blood sugar is greater than 200
three times, start insulin drip, etc.).
t. Therapeutic duplication may be necessary for timely, safe and efficient patient care.
Therapeutic duplication is the practice of prescribing multiple medications for the same
indication/purpose. Therapeutic duplication is allowed when criteria exist (i.e., policy,
guideline, delegation protocol, or the order itself) of when one medication should be
administered over another medication or in combination (e.g. multimodal therapy for pain).
1. For as needed (PRN) orders, when multiple routes exist for the same indication,
the enteral route (oral, tube) is preferred unless:
A. a faster onset of action is necessary; or
B. the patient is unable to use the enteral route (e.g. nausea/vomiting,
strict NPO, continuous suction);
2. For as needed (PRN) orders, when the same routes exist for the same indication
the patient’s prior experience in terms of efficacy with available medication
choices (e.g. milk of magnesia has worked better in the past and polyethylene
glycol) may guide medication selection.
3. An ordering provider should be contacted whenever it is unclear what medication
should be given.
4. An ordering provider should be contacted if an adverse reaction or intolerance
occurs that may warrant a change to the patient’s orders.
u. Range orders.
1. Range orders are orders in which the dose varies over a prescribed range,
depending on the situation or the patient’s status.
2. Orders for dose ranges are acceptable, when all of the following are met:
A. When specific instructions (e.g. correction insulin dosing based on blood
glucose measurement, or benzodiazepine based on an alcohol
withdrawal assessment score) are absent, the maximum dose in the
range must not exceed two times the lowest dose in the range, with the
exception of opioids, which must not exceed four times the lowest dose.
Any dose range may be ordered if dose selection will be directed by an
ordering provider upon administration (e.g. sedation, procedures).
i. For example diphenhydramine 12.5mg-25mg is allowed,
whereas diphenhydramine 12.5-50mg is not allowed because
non-opioids allow a maximum of a 2-fold range.



UW HEALTH CLINICAL POLICY 5
Policy Title: Patient Care Orders
Policy Number: 3.4.2

ii. For example morphine 5-20mg is allowed, whereas morphine
2-10mg is not allowed because opioids allow a maximum of a
4-fold range.
B. There is no range in frequency.
i. If a range in frequency (i.e. every 4-6 hours) is ordered it will
be carried out as the lower number in the range (i.e. every 4
hours)
C. Ordered with an as needed PRN frequency.
i. Scheduled range orders are allowed only with specific
instructions. For example insulin 5-20 units subcutaneously
three times daily, Determined dose with meals using
carbohydrate ratio of *** units/ *** gram of carbohydrate)
3. Range orders shall be interpreted as follows:
A. Assessment: Patient-specific factors (e.g., prior use of medicine, patient
age, comorbidities, past response, underlying illness, and adverse drug
reactions) should be assessed prior to selection of a dose in a range.
B. The lowest dose in the range should be selected unless the assessment
indicates the need for a larger dose.
i. For example: an order for prochlorperazine 5-10mg IV every 6
hours for nausea. Patient has never received this medication
before so the first dose should be 5mg.
ii. For example: an order for oxycodone 5-20mg PO every 4
hours for pain. At home a patient has been requiring 10mg to
control pain, so starting at 10mg could be appropriate.
C. Dose increases:
i. If a patient does not adequately respond to a dose, subsequent
doses may be increased incrementally in multiples of the
lowest dose.
a. For example: if a patient has an order for oxycodone
5-15mg PO every 4 hours, the starting dose would be
5mg. If pain is not adequately controlled after giving
appropriate time for onset/peak effect of the
medication, the clinician may give 10mg. If the
patient continues to have inadequate pain control, the
clinician should call the provider as no more than
15mg can be given within 4 hours.
ii. The time interval (e.g. every 4 hours) should be interpreted to
limit the total dose administered to the maximum dose in the
range.
a. For example: Oxycodone 5-15mg every 4 hours, if a
dose is given at 1200, then the total amount of
oxycodone given until 1600 may not exceed 15mg
without an additional order.
iii. Wait at least 15 minutes following an IV dose or at least 30
minutes following an oral dose before the next dose is given
(unless order indicates a dose can be given sooner i.e. every 6
minutes).
iv. If the desired response to a medicine has not been achieved
using the highest dose in the range, a ordering provider should
be notified.
D. Dose reductions: A subsequent dose of medicine can be lower if a
patient experiences adverse effects or based upon the assessment of
other patient factors (e.g. patient preference, resolution of underlying
illness). If a dose lower than the prescribed range is needed, contact
the ordering provider for a new order.
4. If a clinician is unclear as to which dose to initiate or continue treatment with, an
ordering provider should be contacted.
iv. Linked orders
a. “Followed By” linking indicates that specific medication orders should occur in succession.



UW HEALTH CLINICAL POLICY 6
Policy Title: Patient Care Orders
Policy Number: 3.4.2

Upon linking medication orders with “Followed By” logic, Health Link automatically
calculates the start time of the next order based on the end time of the previous one.
When the first medication order ends, the next order in the sequence begins.
1. The most common application of “Followed By” linking is medication tapers.
2. Procedure orders cannot be linked with “Followed By” logic. This type of linking is
available only for medications.
b. “And” linking indicates that a group of orders are part of the same treatment regimen and
should be reviewed together. Medications and procedure orders can be linked together in
any combination using “And” linking.
v. Pediatric medication orders.
a. It is the responsibility of the ordering provider to determine when weight-based dosing is
required.
b. During the medication order review process, the pharmacist will evaluate the patient
weight in kilograms, dosing formula (e.g., mg/kg) and total calculated dose for every
medication order to ensure dosing accuracy and appropriateness for the patient.
vi. Chemotherapy orders: More detailed requirements are referenced in UW Health Clinical Policy
#6.1.1, Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration,
Documentation, and Patient/Family Education.
vii. Medication Use Policies
a. There are many medication use policies and protocols that influence the ordering process
including:
1. UWHC Policy #8.17, Administration of Medications
2. Pharmacy Departmental Policy #3.5, Patient’s Own Medication Storage and Use
3. Pharmacy Departmental Policy #9.1, Non-Formulary Medications for Inpatient
Use
4. Pharmacy Departmental Policy #3.4, Automatic Stop Dates
5. Pharmacy Departmental Policy #13.19, Infectious Diseases Section Approval of
Orders for Restricted Antimicrobial Agents
6. Delegation Protocol Number 13: Medication Therapeutic Interchange-Adult-
Inpatient
D. Hospital Patient Care Orders
i. It is expected that hospital patients in inpatient, observation, or outpatient short stay status will have
a set of patient care orders to initiate patient care. Patient care orders should be submitted within
one hour of hospitalization.
E. Hospital Ordering System.
i. Hospital order processing.
a. All orders are reviewed, acknowledge and/or verified by a registered nurse as well as
other disciplines as appropriate within their scope of practice. (See Nursing and Patient
Care policy #6.29, Processing Patient Care Orders for additional information).
b. Stat orders
ii. STAT order processing and communications - Ordering provider personally notifies HUC (or RN or
pharmacist) of the STAT order to ensure timely order processing. Additional expectations for STAT
medication orders are outlined in UW Health Clinical Policy #6.1.7, Management of STAT
Medications for Inpatient Units.
F. Leave or Pass orders
i. Refer to UW Health Clinical Policy #2.3.27, Inpatient Absence Policy.
G. Orders for patients being discharged.
i. See UW Health Clinical Policy #2.1.25, Discharge Planning Process, for information relating to
patients being transitioned from inpatient to another level of care.

V. COORDINATION

Author: Manager, Drug Policy Program
Senior Management Sponsor: VP/Chief Nursing Officer
Reviewers:, RN Director Clinical Support, Director Radiology Services, Director Outpatient Rehab, Director
House & Med Staff Admin, Corporate Counsel, Program Director, Pharm Med Use & Innov, Pharmacy
Regulatory Compliance Officer
Approval committees: UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: August 21, 2017



UW HEALTH CLINICAL POLICY 7
Policy Title: Patient Care Orders
Policy Number: 3.4.2


UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES
Several related policies and procedures have been developed, coordinated and maintained by the utilizing
services.
ξ Delegation Protocol Number 13: Medication Therapeutic Interchange-Adult-Inpatient
ξ Nursing and Patient Care Policy #6.29, Processing Patient Care Orders
ξ Pharmacy departmental Policy #13.19, Infectious Diseases Section Approval of Orders for
Restricted Antimicrobial Agents
ξ Pharmacy Departmental Policy #3.3, Pharmacist Clinical Monitoring
ξ Pharmacy Departmental Policy #3.4, Automatic Stop Dates
ξ Pharmacy Departmental Policy #3.5, Patient’s Own Medication Storage and Use
ξ Pharmacy Departmental Policy #9.1, Non-Formulary Medications for Inpatient Use
ξ UW Health Administrative Policy #6.18, UW Health Approved Abbreviation List
ξ UW Health Administrative Policy #8.75, Credentialing and Professional Privileging of Advanced
Practice Providers
ξ UW Health Clinical Policy #1.2.8, UW Health Patient Care Delegation Protocols
ξ UW Health Clinical Policy #2.1.25, Discharge Planning Process
ξ UW Health Clinical Policy #2.3.27, Inpatient Absence Policy
ξ UW Health Clinical Policy #6.1.1, Chemotherapy Process: Informed Consent, Ordering,
Verification, Administration, Documentation, and Patient/Family Education
ξ UW Health Clinical Policy #6.1.10, Medication Reconciliation
ξ UW Health Clinical Policy #6.1.7, Management of STAT Medications for Inpatient Units
ξ UWHC Policy #8.17, Administration of Medications
ξ UWHC Department of Hemodialysis Policy #1.0, Scope of Services delivered by UWHC
Hemodialysis Department
ξ Related Reference A: Range Orders
ξ Related Reference B: Therapeutic Duplication

VIII. REVIEW DETAILS

Version: Revision
Last Full Review: November 30, 2017
Next Revision Due: November 2020
Formerly known as: Hospital Administrative Policy #8.16