Calling Physicians, Transcribing, Giving Change of Shift Report

Question 1

Ideally, accept only w_____ or EMR orders. TO are permissible when i_____ treatment and MD isn’t available to actually write order, new information becomes available and the TO will enable you to expedite e_____ care, very late/middle of the n_____, RN is providing care to patient at h_____.

Answer 1

WRITTEN

IMMEDIATE

EMERGENT

NIGHT

HOME

Question 2

Before calling know exactly why you are calling. Select a_____ physician & phone number. Gather and review a_____ appropriate data. Have factual d_____ of patient status change. A_____ what the MD will need to know. W_____ down all problems, questions & concerns. What do you need/want from the MD. Determine whether anyone else needs to speak to the same physician.

Answer 2

APPROPRIATE

ALL

DESCRIPTION

ANTICIPATE

WRITE

Question 3

When calling have the c_____ open in case MD answers instead of service or voicemail. Leave your n_____, the patients n_____, the p_____ and your d_____ number for return call. Communicate the call out per-unit policy. Document call per hospital policy. If no call back in _____ minutes call again.

Answer 3

CHART

NAME, NAME, PROBLEM

DIRECT

15-20

Question 4

During the call introduce your self and then speak with a_____. State the exact r_____ for calling. Paint a picture for the MD to see and understand the situation, be clear and concise.

Answer 4

AUTHORITY

REASON

Question 5

Do not make d_____, but verify that the M.D. is aware of your concerns. Received orders, write them down as s_____. Have M.D. slow down as needed. C_____ anything unfamiliar, unclear, or confusing.

Answer 5

DEMANDS

SPOKEN

CLARIFY

Question 6

Check your notes to make sure all concerns were addressed. Ask what if and when questions. R_____ back all orders before hanging up. Thank the physician.

Answer 6

REPEAT

Question 7

If you’re having trouble understanding the physician, blame it on a bad connection have the doctor repeat. Have the doctor on speakerphone. Paper chart system can have Dr. fax in order. Electronic health record - When can I expect you to put that order in?

Answer 7

If you get an on-call physician introduce yourself, state, I am calling about Dr. Smith’s patient Mr. Hill. Ask if the doctor is familiar with the patient. Be prepared to give history and background if doctor is not familiar. Make sure you get the doctor’s name.

Question 8

After the call with paper charting document in the patient’s chart: date and time, write the order verbatim, sign with M.D., you and title, whoever listened to the order with you and their title.
T.O. Dr. Smith/J. Schairer, SNARC/P. Hill, RN
The physician countersigns the order within the facility time limit, usually 24 hours

Answer 8

After the call in EHR system ideally, MD puts in the order from off unit location. RN types the order in the system if MD does not. MD will be prompted to cosign the telephone order next time he/she logs into the computer system.

Question 9

Moving information from orders to the chart is known as ______. We are in and unit secretary can transcribe. ______ is the RN who signs off on the transcription. Signing off occurs in both systems.

Answer 9

TRANSCRIPTION

NOTING - ONLY RN CAN NOTE ORDERS

Question 10

For transcribing and noting in a paper system review all orders for any stat or now orders. Make sure you can read/understand the order. Call Dr. it’s unclear. Transfer to the ______ using pencil and/or ______ using pen.

Answer 10

KARDEX

MAR / CHART