Mistakes and inaccuracies in the orders, such as incorrect or missing doses (e.g., magnesium sulfate 16 g instead of 16 m Eq), routes, frequencies of administration, and rates of infusion; typos; and spelling errors, particularly with drug names An exhaustive variety of medications to cover every possible scenario a patient may face (e.g., orders that include multiple analgesics by various routes, laxatives, antacids, a bedtime sedative, antidiarrheal, antiemetic, and others); we’ve previously called these “Don’t bother me” orders, which lead to crowded medication administration records and leave treatment decisions to nurses’ subjective, variable judgment Dosing guidance not provided (e.g., mg/kg or mg/m2 dose not specified along with the calculated dose, particularly for neonatal/pediatric drugs and chemotherapy; safe dose range or maximum safe doses not specified; dosing parameters for titrated drugs not provided) Critical clinical decision support information, reminders, precautions, and/or safety measures not included, such as: monitoring requirements; administration precautions; adjustments for renal impairment or age; maximum adult total dose of acetaminophen not to exceed 3 to 4 grams per 24 hours The format of standard order sets can make them easier to read and comprehend, remind staff to document pertinent information about the patient and prescribed therapy, and draw attention to important information.
Elements of format include font style and size; use of white space; adequate space for handwritten entries; arrangement of the information; prompts for information; appropriate use of symbols, abbreviations, dose designations, punctuation, and capitalization; layout and design of the orders and other important information; and directions for using the standard orders.1-4 Examples of frequently observed problems with the format of standard order sets are provided below.
If the stock bottle for that medication has been thrown away, the resulting expiration date is either the expiration date on the label or 12 months, whichever date is less.
They can be employed by a healthcare organization, physician, licensed independent practitioner, or work as a contracted service.
This practice brief will explore some of the benefits and challenges of scribes within the physician practice setting.
With the push to develop and deploy electronic health records (EHRs) and the need for more detailed documentation, there is a growing concern in the medical community regarding the time expended to capture information-electronic or otherwise.
The time providers spend during a patient visit capturing and entering data rather than focusing on the patient can be a hindrance to the quality of care.