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24 Things To Remember about Order Entry

1. ICD-9 Codes! You have the power! Enter them!


2. All meds HAVE to have an ICD-9 code. PRN meds MUST have a For: documented
as well. Instead of Supplement, put a code for WHY they need the supplement:
Unspecified Nutritional Deficit, Unspecified Vitamin (B/D/C) Deficiency,
Osteoporosis, Anemia, Decubitus Ulcer, etc.
3. Capsules and Extended Release: Do not crush! (Protonix: Do not open)
INCLUDING POTASSIUM! Potassium for patients with crushed meds or PEG tubes
needs to be liquid or dissolved in water or juice and stirred until dissolved.
(About 20cc does it.)
4. Supplements go under Supplement, not Other
5. Fluid Restrictions are Diet orders.
6. All Residents must have Code Status, Weekly Skin Assessments, Monitor for Pain,
and Diet orders
7. If no diet on admission: Use nursing judgment (NAS for hypertension, RCS for
diabetics, Renal for dialysis, etc.). For textures, if not in hospital paperwork,
once again use judgment and make sure Speech Therapy evaluates for most
appropriate diet.
8. Labs NEED a schedule. If they are one-time or STAT labs, put them in as such
with OTO or STAT schedules. On One Time orders, the schedule is Every Day and
Night Shift starting at Midnight the day the order starts and ending after duration
1 day.
9. If labs are to be repeated in 1/3/6 months, schedule them as Regular/Every Day
and Night Shift/Every X Months/fill in frequency and day of the month it will
repeat on.
10.IF YOU ENTER A LAB IN PCC, ENTER IT IN PROLAB. You can write repeating
orders in ProLab. If you dont have access, see ADON for a user name and
password. If for some reason you cannot enter it (i.e. ProLab website down (it
happens)), call ProLab and schedule over the phone, document **NEEDS TO BE
IN PROLAB** in the 24hr report and pass on to the oncoming nurse to input when
the system resumes (in order to generate the requisition.)
11.For UA/C&S: These are the ONLY LABS you can leave unscheduled in the
computer if the resident does not have a Foley and is uncooperative with
collection. In this case, the nurse who successfully collects the UA needs to D/C
the order in PCC with the reason completed; otherwise it will be assumed that
it was not collected. Nurses need to check the computer daily for UA orders in
the computer and collect/DC as indicated. Please write a nurses note for each
attempt, successful or unsuccessful, to leave a record of attempts.
12.If entering an order requiring assessment, be SURE to add the supplemental
documentation to document that assessment. Writing BP q shift does nothing
if a)it doesnt pop up on the LN MAR or b)there is nowhere to document the
blood pressure you just took.
13.Breathing treatments require: BP, PULSE, RESPIRATIONS, O2 SATS, and
MIN(minutes @ bedside). Blood pressure medications (NOT DIURETICS) require
both B/P AND PULSE (as a NP once told me, a blood pressure is useless without a
pulse. The two together tell the story.) Digoxin requires an APICAL PULSE.

24 Things To Remember about Order Entry


14.Nurses: If you get a Coumadin order that reads Give Xmg for x days then
repeat labs, enter the Coumadin order as a regular order and enter a HOLD
date for the end of the order. That way, if the order is given to continue same
dose, you simply remove the hold, but if it changes, you can D/C and start over.
This way, we are not letting duration orders expire without any reminder to
check the new results.
15.The standard Admission orders need to be edited before you save them. Admit
To: must say Inspiration Hills Rehabilitation Center. Admit to the care of: must
say the name of the assigned PCP. Any scheduled assessments or procedures
need to have their schedules added. Change any incorrect shift information (i.e.
11-7) to the correct times for the facility (i.e. 10-6).
16.Unless there is a signed OOH DNR with the resident upon admission, ALL
residents are Full Codes until documentation is produced or told otherwise by the
Social Worker. A temporary physicians order for DNR may be obtained at the
discretion of the physician for no more than 24hrs.
17.Multiple schedules can be entered under the same medication. If an order reads
Give 1 tab TID scheduled and q6h prn, you can add a Regular and a PRN
schedule without making two separate orders. If an order reads Give 1-2 tabs,
you add one schedule for 1 tab and one schedule for 2 tabs (remember to do the
math for the 2 tabs!)
18.If an order reads Give 1 tab q4-6hrs prn, you only have to enter the q4h prn
schedule. It will cover both. So, if you get an order for Give 1-2 tabs q4-6hr
prn, you only have to order 2 schedules: one for 1 tab q4h prn, and one for 2
tabs q4h prn.
19.If giving more or less than one of any medication, you MUST do the math in the
Additional Directions section. So if giving half of a 25 mg pill, write Give tab
to equal 12.5mg. If giving two 20mg tabs, write Give 2 tabs to equal 40mg.
Same goes for liquid medication. If giving 30ml of 10g/15ml liquid medicine,
write Give 30ml to equal 20g.
20.Always write dosing information for liquid medication in terms of volume, not
milligrams. Yes, this requires you to write out math. Medication Aids are not
supposed to calculate dosage by law, so even though they may know that 15mL
of Lactulose is 10g, you still shouldnt write Give 10g Lactulose. Everything
should be in mLs. (cc is on the DO NOT USE abbreviation list, and means the
same as mL.) The only exception is Miralax, where it is okay to write 17g
because there is no entry for one capful.
21.Be careful when transcribing mg, mcg, g, and ui. These are not 1:1
interchangeable AT ALL. 1000mg of Vitamin B is 1000X the acceptable dose;
1000mcg or 1mg is acceptable. 400mg of Vitamin D3 is equal to 40,000IU (and
IUs vary by potency and concentration of the medication). Avoid med errors:
Check your units!
22.If a Duplicate Order error pops up when trying to save the medication, go to
the Dash
tab on the residents profile and scroll down to Alerts. Click the triangle with
the exclamation mark in it next to the medication and find out what it is flagging.

24 Things To Remember about Order Entry


Sometimes it will be something like, This person is taking a multivitamin AND
vitamin d and nothing needs to be done. Sometimes it will be This person is
on 5 different blood pressure pills and you should call the MD and see if they
want to change or d/c some of them. Sometimes its a flat-out duplicate and one
of the orders needs to be discontinued. (Be very careful when discontinuing
duplicates; some residents are on different doses at different times, or have
combination doses, or alternate days. Reading Comprehension!)
23.If you dont know how to do something in PCC, cant read an order, or are having
trouble, I dont know how is NOT AN EXCUSE. Ask another nurse, your DON,
ADON, Supervisor, On-Call, or Medical Records; if we dont know, well find you
someone who does.
24.When admitting a new patient, put in allergies and sex of the resident BEFORE
you put in other orders. This will prevent you from having to confirm every
single order by hand.