Module 4 ORDER IT RIGHT WRITE IT RIGHT

Module 4 ORDER IT RIGHT, WRITE IT RIGHT Critical Communication: Reporting Critical Lab Values NPSG #2: Improving Effectiveness of Communication

Timeframe for Telephone Orders • Telephone orders MUST be reviewed and signed by a physician within 48 hours

Obtaining Telephone Orders • Licensed nurses, CPs, RDs, PTs may accept and implement medical orders • Pharmacists may accept verbal orders DIRECTLY from a physician

Requirements of an ORDER • Signature of the transcribing person • Date and time of order • Type of order, be it Verbal or Telephone

Read IT Back • ALWAYS Read It BACK – After the order is transcribed, it must be read back to the physician

Receiving Critical Lab Result • Always do the following after receiving a critical lab result: – Write it Down – Read it Back – Document – Date and Time

Unapproved Abbreviation • QD, QOD • U or IU • MS, MSO 4 or Mg. SO 4 • Trailing Zero or Lack of Leading Zero

Handoff Communication • Situation • Background • Assessment • Recommendation

Definition of Report • Report is providing information pertaining to the patients. It is generally given by the nurse in charge of the patient to the next provider of care. It provides the opportunity to provide information regarding the condition of each patient and any changes that have occurred during the shift.

Characteristics of a Report • Reporting is a transfer and acceptance of patient care responsibility achieved through effective communication. • Reporting is an interactive communication, allowing the opportunity for questioning between the giver and receiver of patient/client/resident information. • Reporting includes up to date information regarding the patient care, treatment and service, condition and any recent or anticipated changes.

Characteristics of a Report • Reporting requires process for verification of the received information including repeat-back or read-back as appropriate. • The receiver of the report has the opportunity to review relevant patient historical data, which includes previous care, treatment, or services. • Reporting is required for all patients. REPORTING is HANDING-OFF your patient to the next provider of care