Question

The nurse must take a verbal order during an emergency on the unit. Which of the following guidelines can be used for taking verbal or telephone orders? (Select all that apply). a. Only authorized staff may receive and record verbal or telephone orders. The health care agency identifies in writing the staff who are authorized. b. Clearly identify patient's name, room number, and diagnosis. c. Read back all orders to health care provider. d. Use clarification questions to avoid misunderstandings. e. Write \({ }^{\prime \prime} \mathrm{VO}^{\prime \prime}\) (verbal order) or "TO" (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse.

Short answer

Authorized staff should record verbal or telephone orders, clearly identify patient details, read back orders, use clarification questions, and properly document the order with 'VO' or 'TO', including all pertinent information and signatures.

Step-by-step solution

- Authorize Personnel

Confirm that only authorized staff may receive and record verbal or telephone orders, as specified by the health care agency's written policies.

- Patient Identification

Ensure information such as the patient's name, room number, and diagnosis is clearly identified when taking the order.

- Order Repeat

Read back all orders to the health care provider to confirm accuracy.

- Clarify Doubts

Use clarification questions during the verbal exchange to avoid possible misunderstandings.

- Proper Documentation

Correctly document the verbal or telephone order by writing 'VO' or 'TO', and include the date, time, the patient's name, and the complete order. Additionally, sign the names of both the health care provider and the nurse.

Key concepts

Authorized Personnel in Healthcare

The administration of healthcare is a task that requires a significant level of expertise and responsibility. This is particularly true when it comes to following verbal and telephone orders in nursing.

For patient safety and to meet legal requirements, only individuals who have been clearly identified as 'authorized personnel' are permitted to take these orders. These individuals are typically licensed practitioners, such as registered nurses or physicians, who have the training and authority to understand and carry out medical orders.

Healthcare facilities have stringent guidelines outlining who qualifies as authorized personnel, often detailed in their written policies. This serves to minimize the risk of medical errors and ensures that all medical directives are received and executed by individuals capable of interpreting and acting upon them accurately.

Patient Identification in Healthcare

Accurate patient identification is a critical step in healthcare delivery, acting as the cornerstone for safe patient care. When dealing with verbal or telephone orders, it's essential to clearly identify the patient using multiple identifiers.

In practice, this typically involves confirming the patient's full name, room number, and diagnosis. This is not just a formality; it's a crucial verification step that helps prevent medical errors such as administering a treatment to the wrong patient.

Patient Safety Protocols

In implementing patient safety protocols, healthcare workers follow standardized procedures, which often include the use of wristbands, and checklists to ensure that correct patient information is referenced at every stage of care.

Healthcare Order Verification

Order verification is a safety checkpoint in the process of executing medical orders. Whenever a verbal or telephone order is received, it is imperative to read back the entire order to the issuing healthcare provider.

This read-back process acts as a double-check that enhances accuracy and gives both parties an opportunity to correct any potential mishearings or miscommunications.

Importance of Clarity

The strategy of 'read back' emphasizes the importance of clarity over convenience. While it might seem sufficient to simply acknowledge an order, verbal affirmation alone does not provide the necessary assurance that the order has been understood correctly.

Clinical Communication Protocols

Communicating in a clinical environment comes with its own set of challenges and risks. To mitigate these, healthcare organizations establish clinical communication protocols that are designed to streamline interactions and reduce misunderstandings.

These protocols encompass a range of practices, such as using open-ended clarification questions to confirm details and eliminate ambiguities. The importance of clear and precise communication cannot be overstated, as any ambiguity can lead to critical mistakes in a patient's care.

Common Language and Abbreviations

Part of these protocols involves the use of commonly understood language and medical abbreviations to ensure that messages are conveyed quickly yet accurately.

Documentation of Medical Orders

The final step in managing verbal and telephone orders is meticulous documentation. Medical orders must be recorded in a patient's record with all the necessary details: this includes designating the order as 'VO' for verbal orders or 'TO' for telephone orders, and noting the specific time and date the order was received.

The full order, the patient's information, and the issuing provider's name are also captured. Just as crucial is the documentation of the nurse or authorized personnel who took and executed the order, including their signatures. Good documentation is not only about following procedures - it serves as a legal record of care provided and is pivotal in maintaining continuity of care when shifts change or when patient care is transferred between departments.