HUC: Basic Order Transcription

1. HUC: Basic Order Transcription The 4 steps to successful order transcription

2. Objectives : the student will be able to: • identify orders to be processed by checking the chart and selecting the orders • Identify STAT or urgent orders by scanning the orders selecting and processing them first • Process the order by selecting the correct form/requisitions and by correct placement in the Kardex and chart • Mark the order as complete by initialing the orders and following individual facility protocol

3. Step 1: identify order to be processed • The HUC is not always at the desk when a doctor visits and leaves orders • The HUC should always check the doctor’s order sheets of any chart left on the desk for orders ,before returning it to the chart stand • Occasionally the doctor will flag the order : there are a variety of way to do this. Some charts have a dial with a specific colour for orders

4. Step 2: identify STAT or urgent orders • Scan the orders in all chars looking for words or phrases that indicate orders to be processed immediately • Words like STAT, NOW, IMMEDIATELY, RIGHT AWAY • If you see any orders like this inform the charge nurse right away and begin processing as there may be things a nurse has to do that you cannot; follow facility protocol

5. Examples • EKG now • Penicillin 1000mg loading dose immediately then 250mg four times a day for seven days starting tomorrow • Digoxin level STAT • *what is an EKG? What is penicillin used for and what is a loading dose? What is digoxin? Why is it important to check the levels of digoxin in the blood?*

6. Step 3: Process the orders : requisitions, forms, Kardex and MARS • All orders must be processed on the appropriate requisition. For example- a WBC ( white blood count) is ordered on a hematology requisition- whether hard copy or electronically • An MRI is on a MRI requisition as so forth • On the Kardex the tests should be listed in the areas for lab /diagnostic tests pending so they can be erased when the results are back • Follow facility protocol for ordering tests: phone? Deliver Req.? Computer?

7. Placement of orders • Routine medications are entered under routine medication on the Kardex and on the MARS( medication administration records) in the chart – follow protocol whether you write in the order or the nurse when they give the first dose. Remember chart entries are made in pen because they are legal documents and can be entered into evidence in a court of law

8. Kardex PRN drugs are given as needed or requested Routine drugs are taken at set times every day Dressing changes, respiratory therapy IVs: D5W, R/l

9. Medication Administration Records(MARS)

10. Consults • May require a special letter/form to.. • Social work • Occupational therapy • A specialist • Home Care

11. Step 4– the sign off • Signing off on the orders means that YOU have • placed the appropriate calls, filled in the correct form/requisitions, entered information in the chart and Kardex and the nurse can now double check and sign off too • Date, time, your initials • Then leave the chart for the charge nurse , making sure you inform them about the orders