Name of Policy:

Policy Number:

3364-110-04-05

Department:

Nursing Service

Approving Officer:

Chief Nursing Officer/CNO

Responsible Agent:

Chief Nursing Officer/CNO

Scope:

University of Toledo Medical Center (UTMC)

Effective Date:

2.1.2014

Initial Effective Date:

6/1978

___

New policy proposal

_....:.X=--- Minor/technical revision of existing policy

___

Major revision of existing policy

___

Reaffirmation of existing policy

(A) Policy Statement

Nursing staff are to follow appropriate lines of communication when clarifying or questioning medical care.
Medical care includes a physician's order and/or the response given by the physician related to information
provided by the Registered Nurse

(RN).

(B) Purpose of Policy

The

RN is responsible for clarifying any prescribed regimens, direction, or treatment regimen when the RN

believes or should have reason to believe the prescribed order is:

1.
2.
3.
4.
5.

Inaccurate.
Not properly authorized.
Not current or valid.
Harmful or potentially harmful to a patient.
Contraindicated by other information.

(C) Procedure
1.

Efforts to resolve the problem should occur at the lowest level possible. Open, complete, and timely
communication between care givers is essential for patient safety.

2.

The RN must notify the prescribing practitioner when she/he questions the direction, medication, or
treatment as prescribed. If the issue is not resolved, the nurse must go to the next level to get resolution.

3.

The nurse must notify senior residents from the appropriate service or on-call resident, up to the attending
physician if necessary.

4.

If the nurse is unsuccessful in resolving the problem, the nurse should report the problem to the unit
Nursing Director/Assistant Nursing Director or House Supervisor (HS), who will make an effort to define
the problem and resolve the situation. Consultation with the Associate Vice President/Associate
Executive Director and/or Medical Director should be done as appropriate to the situation.

5.

Document in the electronic medical records (EMR) that the practitioner was notified of the decision not to
follow the direction or administer the medication or treatment, including the reason for not doing so. An
occurrence report may be initiated if appropriate.

6.

The intent is always to clarify the order in question by entering a new order in the EMR This is
accomplished by entering a new order and discontinuing the previous one. The EMR will prompt you to
either 'modify' or 'discontinue' the order. Select 'discontinue', then select 'other' and type in the field
that 'clarification of order received.'

Policy 3364-II0-04-05
Clarifying Medical Care
Page 2

References:
Ohio Administrative Code 4723-4-06, S tandards of nursing practice promoting client safety. Retrieved February I, 20I4.
from http://codes.ohio.gov/oac/4723-4-06
Ohio Board ofNursing Decision Making Model. Pub. No: OBN-I03 available at
http://nursing.ohio.gov/pdfs/decmodel.pdf. Retrieved February I, 20I4

Review/Revision Date:

Approved by:

tl.r-_

. . C/t-"'

J?c

Daniel Barbe ,

Le._p..,_;:>

, BSN, MBA

ChiefNursing Officer/CNO

Review: Policy & Standard Committee: 9/13, 2/14

Revision Completed By: Greg Shannon, MSN, RN

J:::tfE::J 'ZC-.?>tc/
Date

I979

I988

6/I8/2008

I980

I989

8/31/20IO

I981

1990

9.1.2013

1982

1993

2.1.2014

1983

1/95

5/1984

1999

1985

4/2001

I986

3/2002

I987

2/2005

Next Review Date:

Policies Superseded by This Policy: 4-05

2.20I7