Diagnostic and Therapeutic Procedure Orders Documentation

There are many diagnostic and therapeutic order types. Diagnostic orders include orders for x-rays, CT, MRI, lab tests, and more for the purpose of diagnosing a patient’s symptoms of ­illness. Therapeutic orders are orders for treatment that either prevent or address illness by way of medication administration, surgery, or counseling. Physician orders are the instructions the physician gives to other healthcare professionals who perform diagnostic tests and treatments, administer medications, and provide specific services to a particular patient. For example, the physician might order a nurse to take the patient’s temperature every two hours. Admission and discharge orders should be found for every patient unless the patient leaves the healthcare organizations against medical advice (AMA), but other orders will vary from patient to patient. All orders must be legible and include the date and the physician’s signature. In electronic systems, signatures are attached via an authentication process discussed in chapter 10, Data Security.

Standing orders are orders the medical staff or an individual physician established as routine care for a specific diagnosis or procedure. Standing orders authorize other healthcare providers (such as nurses) to begin treating the patient ­before the physician examines the patient. Standing orders are commonly used for disease processes and injuries requiring prompt attention. For example, a standing order to all the physician’s patients who are scheduled for an appendectomy would include all the orders commonly needed to get the patient ready for surgery. The physician can then add orders that are specific to a patient; for example, a patient who is scheduled for an appendectomy and who is also diabetic will have different standing orders than a patient with no underlying disease process. Like other physician orders, the standing orders must be signed, verified, and dated.

Physicians may communicate orders verbally or via telephone when the hospital’s medical staff rules allow. State law and medical staff rules specify which practitioners can accept and execute ­verbal and telephone orders (for example, only registered nurses). How the orders are to be signed as well as the time period allowed for authentication also may be specified. Currently, there is technology that allows orders to be sent via mobile devices, such as smart phones and tablets, and healthcare organizations are beginning to explore the possibility of using this technology.