If you haven't already:
Write all of the orders for the patient.
Click Close to return to the Orders For This Session scratch pad.
Click Sign (ALT+S).
Type your clinical key in the field provided. (See Finding Your Clinical Signing Key).
For RNs only:
On units not utilizing the eMAR (electronic medication administration record): To automatically sign these orders as reviewed and transcribed, click the Yes option under Reviewed?.
On units utilizing the eMAR (electronic medication administration record): Orders must be reviewed and transcribed in a distinct process so that applicable orders will be transcribed electronically to the eMAR. See RN Reviewing and Transcribing Orders for the eMAR.
For RNs only, in the main ED (but not ED observation):
Labels print automatically for any order, after it is signed as reviewed when entered by an RN, that should be documented on the ED administration record.
For advanced practitioners only, requiring cosign:
To mark the orders as needing cosign by an MD, click the Yes option under Cosign Required?.
Record the physician's name as described below.
For verbal, approved exception to standing order, or cosign required orders, a field is provided to record the name of the ordering MD. To look up a provider:
Type at least three letters of the last name, followed by a comma (,), and one or more letters from the first name (no spaces).
Press ENTER. The Providers list opens, displaying any names that matched your input.
Click to select a name, or press ENTER to take as typed.
Click OK (ALT+O).
See Fix Wrong MD to change the physician assigned to cosign a verbal order or approved exception to standing order session.
Life-Sustaining Treatment (LST): The three options for LST are active for inpatients, when an MD, NP, PA, or CNM is signing, if there is not already an active LST order. The options include Full Code (discussed with patient/surrogate), Limitation of Life-sustaining Treatment, or the default selection of Full Code (discussion with patient/surrogate not appropriate or possible at this time). Click an option to change the order from the default.
Allergies and Adverse Reactions:
To open the Allergies order form and record known allergies, click Enter Allergies (ALT+E). See Recording Allergies and Adverse Reactions.
If the patient has no known allergies, click NKA (ALT+K).
If you have no information on drug allergies for this patient, click Allergies Unknown (ALT+K).
VTE Mechanical Prophylaxis Documentation: For inpatients on some care units with orders for antiembolism measures, if you can confirm the application of the treatment, click the applicable checkbox to document this information. See Documenting the Application of Mechanical Antiembolism Measures.
Many patients admitted to all MGH inpatient care units must have an assessment for VTE (venous thromboembolism) documented in POE. See Responding to the Prompt for VTE Assessment.
Patients admitted to some MGH care units must have an order that designates their admission status as inpatient, observation, or routine post-procedure recovery (RPPR). See Documenting Patient Admission Status.
Complete the signature: Click OK (ALT+O).