Name of Policy:

Medical Orders

Policy Number:

3364-110-04-03

Department:

Nursing Service

Approving Officer:

Director ofNursing/CNO

Responsible Agent:

Director ofNursing/CNO

Scope:

The University of Toledo Medical Center

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_ _ _ New policy proposal

Major revision of existing policy

---

Effective Date:

9/2012

Initial Effective Date:

1/1981

--=X-=--- Minor/technical revision of existing policy

- - - Reaffirmation of existing policy

(A) Policy Statement

Registered Nurses may accept and implement medical orders which have been prescribed by UTMC residents,
physicians, dentists, and written orders by physician assistants (PA's) will be implemented. Advanced Practice
Nurses who have received prescriptive authority by the Ohio Board of Nursing, may prescribe medications. The
RN shall clarifY any order or treatment regimen when the nurse has reason to believe the order is inaccurate,
non-efficacious, not properly authorized, or contraindicated by other documented information. The nurse shall,
in a timely manner, consult with an appropriate practitioner, notifY the ordering practitioner when the decision is
made not to execute an order, and document that the practitioner was notified including the reason for the action.
Orders which are illegible, improperly written or not understood will also be clarified with the appropriate
practitioner before being carried out.

(B) Purpose of Policy

To clarifY the responsibility of the Registered Nurse, and Clerical Specialist/Medical Assistant regarding the
implementation of physician's orders.

(C) Procedure
1.

Verbal orders will be accepted and received in accordance with hospital policy 3364-100-53-16.

2.

Orders written by Physician Assistants must be prescribed by the supervising physician and not
independently ordered by the PA. The PA's order must be consistent with the PA utilization plan under
which that PA practices. Prior to implementing an order received from a PA, the nurse should be aware
of the scope of practice of the particular PA as defined in the physician assistant's utilization plan. The
supervising physician service has a copy of the PA utilization plan.

3.

The Registered Nurse is responsible for reviewing and verifYing all orders.

4.

The Registered Nurse receiving the verbal or phone order writes down the complete order and then
"reads-back" the complete order. The individual who gave the order confirms the order that was read
back. In code situations or in the OR "repeat-back" is acceptable.
Verbal and phone orders must be flagged by the RN or CS to alert MD that order needs to be co signed.

5.

It is the responsibility of the medical student who writes the orders to arrange for verification by a
licensed physician. Depending on the importance of the order and the patient's condition, the nurse may
need to prompt the medical student to obtain the signature or call the responsible physician him/herself.

Policy 3364-110-04-03
Medical Orders
Page2
6.

Orders which are illegible, improperly written or not understood, will not be carried out until the
registered nurse clarifies the order with the appropriate physician. Refer to policy 33 64-110-04-05
"ClarifYing Medical Order".

7.

No more than one hour prior to the end of a shift, the RN will verity that all orders written during that
shift were transcribed correctly and noted, by signing, dating, and timing in RED under the last
physician order written. If, in the event the medical record is leaving the unit near the end of the shift,
the RN should go ahead and note the orders as stated above. If previous shift nurse was unable to
redline the orders prior to the patient and chart leaving the floor, the previous shift nurse should ask the
oncoming nurse to complete the redline process for the previous shift during bedside report.

Approved by:

~~.v;$&~
Daniel Barbee N, BSN, MBA
Director ofNursing/CNO
Review/Revision Completed By:
Andy Fox, RN, BSN

Review/Revision Date:

Of/1~/ ( '"L
Date

10/81
1982
1983
6/84
11185
1986
1987

1988
1989
7/90
1992
2/93
1/95
1996

8/99
2002
2005
6/2006
4/2009
9/2012

Next Review Date:

9/1/2015

Policies Superseded by This Policy: 4-03

It is the responsibility of the reader to verify with the responsible agent that this is the most current version of the policy.