News and Views for Healthcare Accreditation Professionals

Question:
Prior to surgery, anesthesiology assesses the patient while in the holding room. Based on that assessment, the anesthesiologist knows that for pain relief in the recovery room he is going to prescribe, for example, Dilaudid, for the patient. The hospital uses a post-operative recovery order set, which has on it various medications for post-operative pain. If Dilaudid doesn’t work, the order set allows the anesthesiologist to choose the next med, likely Morphine Sulfate. To initiate all of this, is it acceptable for the Anesthesiologist to sign/date/time the post-operative recovery order set when he does the pre-operative assessment – which is prior to the surgery?

Answer:
It is not acceptable to write and sign orders prior to performing the procedure. In the post-op note situation the practitioner might start the note prior to the procedure, leave it unsigned and after the procedure edit/update as necessary and sign, date and time it to clearly indicate completion after performance of the procedure or at the time the order is needed.

In an orders situation, there would need to be clear evidence that the order was given or activated after the procedure or at the time the order is needed by the patient. This can again be a signature, date and/or time or if your “activation” process can clearly indicate that it was activated by the physician at the appropriate time, not in advance, then an electronic signature or activation would likely be acceptable. It could be activated only by the person giving the order, i.e., the physician, dentist, etc.

In most states nurses or other non-independent practitioners under their scope of licensure cannot determine when an order is required to be activated. We see this issue with preprinted and pre-approved standing order sets. There must be a patient specific order from the physician for the use of the standing order set at the time the set is to be implemented or is determined to be needed by the patient.

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