Wiki ER Charging without Written Orders

mslori7

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Local Chapter Officer
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69
Location
Evergreen Park, IL
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Hi,

One of my charge auditors asked the following question:

Can you please try and help determine if there are standing orders in the ED. If so can you please find out if these are performed can the ED level add the points to the chart without the Written orders.

Example: A patient comes in with Chest pain and is put on a cardiac monitor the patients rhythm is recorded as (NSR) Normal Sinus Rhythm and a order for the monitor was never written,can we add the level points to our tool?

If anyone have any information, I'd really appreciate it!

Lori
 
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