SME: Medical Director
Last Review Date: 6 /6/07
Physicians or designees must follow UTHCPC guidelines when s/he calls for or
enters orders for treatment. Only privileged physicians and residents may enter
orders or provide telephone orders. Most orders will be entered electronically but there may be occasions when handwritten orders are necessary.
Physician's orders may be entered or written to include, but are not limited to, the following:
 | Admitting provisional diagnosis |
| Laboratory/Diagnostic procedure order |
| Transfer/Discharge/Consultation |
| Medication order |
| Other treatment orders |
 | Vital signs |
| Nutritional services |
| Precautions |
| Program services (e.g. groups) |
| Psychology services |
To ensure safe and adequate use of medications, telephone orders must be handled as follows:
Stage |
Description |
1 |
The medical practitioner determines that the patient is in need of an intervention, with telephone communication presenting the swiftest method of accomplishing the order. |
2 |
Licensed staff records/documents the telephone order online in Sunrise and adheres to read back process. |
3 |
After entering the order and before it is carried out, the person who wrote the order reads it back to the physician verbatim. In the case of medication orders spell the name of the drug if it sounds like another drug. Example 1: Orders are transcribed in the metric system, excluding medication/therapies that use standard units such as insulin Example 2: The word "unit" is written, rather than the abbreviation "U" Example 3: For medications prescribed in micrograms, the word "micrograms" is written, rather than the abbreviation "mcg". |
4 |
The person receiving such orders records the physician's name, dates, and times the orders immediately. Physician signature: The ordering physician or the attending physician must authenticate the order by discharge. Exception: Orders for seclusion/restraint or emergency psychoactive medications must be authenticated within one hour and must be done by the physician giving the order. |
5 |
The order is entered by nursing staff. |
The physician must write orders clearly, legibly, and understandably. The pharmacy will not carry out any illegible or improperly written orders. Physician orders are recorded in black ink with the exception of telephone orders (red ink).
Online Process:
Orders must be entered by physicians on the medical staff or the RNs may enter orders in emergency situations.
Under no circumstance is anyone allowed to use another's password.
The attending physician reviews the physician residents' orders.
Abbreviations for medications may not be used on physician's order forms.
Any medications the physician orders and gives to patients must be listed in the following:
| The current edition of United States Pharmacopeia |
| National Formulary |
| American Hospital Formulary Service |
| A.M.A. Drug evaluations |
Only privileged physicians and residents under their supervision can order medications. Only UTHCPC employees with appropriate licensure, certification, or registration can administer medications.
The physician can order and use experimental and investigational drugs only under the sponsorship and supervision of the UTHSCH-MS Department of Psychiatry's research guidelines, and the UTHCPC Research Committee.
Patients admitted to UTHCPC who are taking investigational drugs under a protocol from another institution can receive such drugs at UTHCPC on a written order if the other institution has provided UTHCPC with the following:
| A copy of the protocol |
| A copy of the patient's original informed consent |
| Adequate written information about its pharmacology as follows: |
| Adverse effects |
| Storage requirements |
| Method of dose preparation and administration |
| Precautions to be taken |
| Authorized prescribers |
| Patient monitoring guidelines |
| Any other material pertinent to the safe and proper use of the medications |
The physician may request consultation on critically ill patients when the diagnosis or appropriate treatment is obscure or cannot be obtained at UTHCPC.
The attending physician provides a written/online order requesting a consult for the patient.
Physician's Orders for Seclusion/Restraint
Physician's Order for Admitting Provisional Diagnosis
Physician Order for Ancillary Services
The Joint Commission : Information Management , Medical Staff
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