Wiki ED Doctor Orders missing information

[ANWALKER]

Is it appropriate to send back the order sheet to an ED doc if they did not mark a test or treatment done by the nurse specified on the nursing flow sheet? For example, the docs I code for routinely forget to mark mini caths, saline locks and bladder scans on the order sheet. The nurse documents it was done on the flow sheet. Sometimes they forget to write down meds given also. They may or may not mention it in their dictation. Basically want to know if there is any rule about adding to the orders in the after-math??? If so where is this rule?

Thanks!

 

[LTibbetts]

Not sure if there is a specific rule anywhere. If there is, I am unaware of it, but at the last place I worked, they always made me send back the chart to the physicians for them to complete the orders so that it would be compliant with the charges. We did the same thing if a certain test was cancelled, but the order still showed on the order sheet. However, this may have simply been a hospital specific policy and not required for actual compliance reasons.
Hopefully, someone else will be able to help you find something in writing.

 

[Sueedwards]

I don't know about finding it in writing, put I know from the compliance point of view, we are allowed to take it back and just have the doctor initial next to what he is documenting and the date.