Question

A primary healthcare provider calls the intensive care unit and orders 10 mg of morphine every 4 hours for a patient's pain. what correct actions does the nurse take to record and follow the instructions?

Answer 1

The nurse should document by confirming the patient's name, room number, and diagnosis, when he or she administers a medication. When orders are given by telephone, the nurse carefully notes the prescription and reads it back to the primary healthcare provider for verification. In the report, the nurse indicates whether it is a telephone order (TO) or verbal order (VO) and mentions the name of the patient, complete ordering information, name of the primary healthcare provider, and date and time of the TO or VO; the nurse also documents the order was read back to provider. This is signed by the ordering primary healthcare provider within a set time frame. Vague documentation and informatics can lead to misinterpretation and legal claims.