Documenting Communication With Providers and Unique Events

Question 1

Telephone Calls Made to a Provider

Answer 1

Document every phone call you make to a health care provider. Your
documentation needs to include when the call was made, the number
called, who made the call, who was called, to whom information was
given, what information was given, and what information was received.

Question 2

Telephone and Verbal Orders

Answer 2

Telephone orders (TOs) occur when a health care provider gives
therapeutic orders over the phone to an RN. Verbal orders (VOs) occur
when a health care provider gives therapeutic orders to an RN face-to-face
while they are standing in proximity to each other.The potential for verbal
orders to be misunderstood, misheard, or transcribed incorrectly makes
them error prone, particularly given different care provider accents,
dialects, and drug name pronunciations.Use of VOs is discouraged except in urgent or
emergent situations. TOs and VOs should be used only when absolutely
necessary and not for the sake of convenience for the health care provider.

Question 3

Incident or Occurrence Reports

Answer 3

An incident or occurrence is any event that is not consistent with the
routine, expected care of a patient or the standard procedures in place on a
health care unit or within an agency (Chapter 23). Examples include
patient falls, needlestick injuries, medication administration errors,
accidental omission of ordered therapies, a visitor losing consciousness,
and any circumstances that lead to injury or pose a risk for patient injury
such as a “near miss.”