What are three examples of poor documentation practices in patient records?

Top 9 types of medical documentation errors

• Sloppy or illegible handwriting.
• Failure to date, time, and sign a medical entry.
• Lack of documentation for omitted medications and/or treatments.
• Incomplete or missing documentation.
• Adding entries later on.
• Documenting subjective data.
• Not questioning incomprehensible orders.

Is there ever a situation when the nurse can ignore a physician’s order?

Unless there is a safety concern or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed “neglect.” Safety concerns are one reason why nurses might not follow a doctor’s order.

Does a nurse always have to follow a doctor’s orders?

Any refusal to follow a physician’s order must be based on evidence and standard of care, not just opinion. A nurse needs to know the Board of Nursing standard of care for nurses in her state.

What should nurses document?

Nurses document their work and outcomes for a number of reasons: the most important is for communicating within the health care team and providing information for other professionals, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory and legislative, reimbursement.

Can a nurse refuse a verbal order?

At Community Medical Center’s ED in Missoula, MT, if the physician is physically present, they cannot give a verbal order, and nurses cannot accept these, says Steven D. Glow, RN, MSN, FNP, care flight nurse and adjunct assistant professor at the College of Nursing at Montana State University-Bozeman, Missoula Campus.

What can a nurse do that a doctor can t?

Nurses can’t perform surgeries and other invasive procedures such as endotracheal intubation and surgeries. Doctors make the final decisions in cooperation with other interdisciplinary members of the health care team, while nurses may suggest plans of care.

What can a nurse do without an order?

RNs provide an enormous range of patient care that does not require a doctor’s order. Like your doctor, your nurse uses specific processes, training, and skills to diagnose problems and develop a plan to treat them.

What happens if you don’t follow doctors orders?

Your doctor’s diagnosis and treatment plan are useless if you don’t follow his or her advice. Patients who do not follow their doctors’ orders, especially patients with chronic conditions, may experience health complications, rapid disease progression, decreased quality of life and even premature death.

What happens if a nurse fails to follow a doctor’s order?

Unless there is a safety concern or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed “neglect.” Safety concerns are one reason why nurses might not follow a doctor’s order.

What should a nurse do if an order is unsafe?

The nurse may feel it is unsafe due to a potential transcription error. If nurses encounter orders that they feel are unsafe, they should first consult with a peer or charge nurse. Bringing it to the supervisor or manager’s attention is also mandatory.

Can a nurse take a verbal order from a physician?

For example, a physician may ask the nurse to take a verbal order when the facility has EMRs. The nurse may feel it is unsafe due to a potential transcription error. If nurses encounter orders that they feel are unsafe, they should first consult with a peer or charge nurse.

What are the Physician’s Orders?

As was noted in a previous Signposts for Compliance column, the physician’s orders provide the road map that tells clinicians how to get a home care patient from admission to discharge ( Zuber, 2003 ). The physician’s orders are truly the heart of the Medicare Plan of Care (POC).