What are the guidelines for evaluating a doctor's order in a patient's chart?

Guidelines for Evaluating Doctor's Orders in a Patient's Chart

All doctor's orders in a patient's chart must be clearly documented in writing, as verbal orders pose potential risks to patient safety and quality of care. 1

Documentation Requirements

• All medicinal products, including oxygen and other non-prescription medications, must have a clear written record when administered to patients by healthcare professionals 1
• Orders should ideally be prepared at the time treatment is initiated, though in emergencies, clinicians may treat first and subsequently document all treatments given 1
• Each hospital should have an agreed policy and protocol for ordering medications to allow staff to adjust delivery and administer treatments in emergency situations prior to the availability of a written order 1

Key Components of Proper Order Documentation

• Orders must be clearly communicated to the person who actually administers the treatment to the patient 1
• An accurate record must be kept of exactly what has been given to the patient 1
• Documentation should be straightforward, comprehensible, and use appropriate formatting to ensure legibility 2
• All documented information must be factual and objective, and notes should be reviewed for errors before finalizing 2

Electronic Order Entry Systems

• Computerized physician order entry (CPOE) systems have been shown to reduce prescribing errors by approximately 66% in adults 3
• Electronic order sets can promote safe, efficient, and evidence-based patient care when properly designed 4
• Pharmacy validation in a computerized order entry context provides an important secondary filter for eliminating errors 5

Order Evaluation Process

• Healthcare professionals should verify that orders are:
  • Complete with patient identification, medication/treatment details, and timing 6
  • Accurate with appropriate dosing and administration instructions 6
  • Appropriate for the patient's condition and consistent with evidence-based guidelines 1
  • Free from potential drug interactions or contraindications 6

Special Considerations

• For patients with multimorbidity, orders should be evaluated with consideration of potential drug interactions and the overall treatment burden 7
• For procedural orders, documentation should include a time-based record of administered drugs (name, route, site, time, dosage) and patient effect 6
• "Time out" confirmation of patient name, procedure, and site should be documented for procedural orders 6

Common Pitfalls to Avoid

• Failing to document when vital signs cannot be obtained due to patient non-cooperation 6
• Omitting medication history that could interact with treatments 6
• Inadequate documentation of allergies and previous adverse reactions 6
• Not documenting baseline health status for comparison during treatment 6

Quality Improvement Considerations

• Regular review of documentation practices to identify areas for improvement 2
• Participation in peer review of documentation to maintain quality standards 2
• Implementation of a multidisciplinary team approach, especially involving clinical pharmacists when available 7

Remember that good order documentation is essential for patient safety, continuity of care, and legal protection. Orders should be evaluated not just for technical correctness but for their appropriateness in the overall context of the patient's condition and care plan.