The HUC's Role in Processing Physicians Orders

A chart that has been flagged means that:

• the health information management system (HIMS) is involved because the doctor is on suspension.

• the chart is off the floor because the patient is receiving therapy off the unit.

• a lawsuit for negligence is possible.

• the chart is awaiting transcription because the doctor has written new orders.

Antacid of choice as needed for dyspepsia is an example of a _____ order.

• prn

• standing

• short series

• stat

An order that is in effect and is executed routinely until discontinued or changed by doctors’ orders is a _____ order.

• stat

• short series

• one-time

• standing

The Kardex system is useful for:

• keeping track of nonclinical supplies on the nursing unit.

• viewing surgery schedules for patients on the nursing unit.

• viewing the employee work schedule.

• viewing the patient’s current orders.

Which of the following orders should be transcribed first?

• MOM 15 mL PO q8h prn constipation

• Stat EKG with severe chest pain

• CXR PA/LAT in AM

• Demerol 50 mg IM on call to endoscopy

An order that is executed according to its qualifying phrase and is automatically discontinued after completion is a _____ order.

• prn

• standing

• short-series

• stat

To avoid transcription errors, the HUC should:

• not allow anyone to have the patient’s chart until the orders have been transcribed.

• make a notation on a notepad of orders that have not been completed.

• write symbols such as, ord, K, or M in ink in front of or above each doctor’s order on the doctors’ order sheet to indicate completion of a transcription step.

• take a break in the middle of a complicated set of doctors’ orders.

A stat order also may be noted as:

• ASAP

• directly

• immediately or now

• written in red so as to indicate its urgency

An order written EKG now would be ordered:

• to be done as soon as the EKG technician arrives on the floor.

• as soon as any available technician might be able to perform the study.

• as soon as the department sees the order on the computer.

• stat.

The purpose of the use of symbols when the HUC is transcribing orders is to:

• alert the doctor that the order is completed and where he or she can locate the examination results.

• alert the nurse that the order has been transcribed and when he or she should expect it to be completed.

• indicate to the HIMS department that the order has been transcribed.

• indicate completion of that particular transcription step.