Review and/ or Transcribe New Orders

• On care units utilizing the eMAR (electronic medication administration record), all orders must be reviewed and transcribed in the eMAR so that applicable orders will be transcribed electronically to the eMAR. The eMAR RN Review/Transcribe function opens automatically on eMAR care units. See RN Reviewing and Transcribing Orders for the eMAR.

• In the main ED (but not ED observation), labels print automatically for any order that should be documented on the ED administration record. See the Overview of ED Administration Order Label Printing for more information.

• See also Overview of RN Review and Transcribing Orders

• If you haven't already, open the Review and Transcribe list.

1. Select the patient.

2. Click Transcribe/RN Review (ALT+T) or RN Review.
   Nurses in the Emergency Department  (ED) print labels for the ED administration record rather than transcribe, so RN Review is the only option.

3. If prompted, click to select the option to either RN Review only, or RN Review and Transcribe, then click OK (ALT+O).

• This prompt is triggered only when BOTH transcription and RN Review are needed (non-ED patient, status = Pending). If all of the orders are Reviewed (patient status still = Pending), you can still Transcribe, and if all are Transcribed (patient status = <T>) you can Review.

• In the main ED (but not ED observation), orders are not transcribed—labels print automatically for any order that should be documented on the ED administration record.

4. If the patient has been moved from the main ED to observation or admitted to an inpatient care unit, the responding clinician should write new orders and discontinue the orders from the ED. If the new orders are written in a pre-admission session, all active orders will be inactivated automatically when the pre-admit orders are activated. See Writing Pre-Admission Orders and Activating Pre-Admission Orders.

5. If the patient has been admitted from the ED without pre-admission orders, and there are still active orders from the ED, you will be prompted to inactivate the ED orders before continuing. Click Inactivate ED orders (ALT+I).

6. If the allergy record was updated in the ED, the order(s) must be resigned. MDs, NPs, PAs, and CNMs are authorized to resign. Operations staff, who are not authorized to resign, must click OK (ALT+O) when prompted, and notify an authorized provider that the resign is required.

• To RN Review orders, and transcribe if you selected the option:

7. The first order listed is selected automatically; click to select another if needed.
   Orders are flagged in the columns to the right if they have already been signed, as follows: R = Reviewed by RN; T = Transcribed.

8. Click RN Review or RN <T> Review (ALT+R).

RN Review = Reviewing only; sets R in status
RN <T>/Review = Transcribing, sets T in status, with Review (R in status) if not done

To remove unsigned flags for a selected order, click RN Review or RN <T>/ Review again. You cannot undo review or transcription once it's signed off, whether someone else signed or you did.

9. If all of the details of the order are not visible, the Zoom detail view opens automatically. Click Close (ALT+C) to return to the list.

Automatic zoom is not triggered for orders flagged as <ED Order Only>.

10. The next order in the list is selected automatically. Repeat the process for all pending orders.

11. When all orders are processed as needed, sign the transcriptions.

• To print, click the line for the order

• For a paper copy of the order, click Print Order.

• For a requisition, click Print Requisition. The button is active only if the selected order has a POE requisition.

• For  transfusion product pickup slip,  click Print Requisition. (The button is active only if the selected order is for a BTS transfusion product.)

• To open KnowledgeLink  

• Click .

• Click Exit (ALT+E) to close KnowledgeLink.

• Click Pop Out (ALT+P) to open KnowledgeLink in a separate window from the CAS.

• Toggle between Order Entry and KnowledgeLink by clicking the icons in the taskbar.

• Click to close the KnowledgeLink window.

• If you are transcribing, complete any actions required for the order:

• Complete paper forms, phone calls, and faxes as required to process the order.

• Lab labels—Orders that start with [Lab Labels] have been automatically transmitted to the clinical laboratory system. Sticky labels that can be applied to the lab specimen are printed at the care unit. Labels for STAT testing print as needed on the designated STAT label printer. Labels and collection lists for routine collections print to the designated care unit printers on a schedule (each care unit has its own schedule).

• POE Requisitions—Orders that start with [POE Req] must be sent to the lab with a requisition printed from Order Entry. Select the order on the Review & Transcribe list and click Print Requisition (ALT+P). See also Printing POE requisitions for orders that are already transcribed and RN reviewed.

• Lab requisitions—Orders that start with [Lab Req] must be sent to the lab with a pre-printed requisition from the lab. Complete the requisition from the order information. All tests for codes, blood bank, HLA, cytology, pathology, and research use pre-printed lab requisitions.

• Medication orders transmit directly from Order Entry to the pharmacy.

• At RN Review, medication orders are automatically transcribed to the electronic medication administration record (eMAR) for documentation.

• Food and nutrition orders for oral diets transmit directly to the dietary system.

• Radiology exams must be ordered via MGH Radiology Order Entry (ROE): http://mghroe.partners.org

• To add notes to a selected order, or to view existing notes:

1. Select the order and click Annotate (ALT+A).

2. To create a note:

• Click New (ALT+N).

• Type in the field provided, then click OK (ALT+O).

• Type your signing key, then click OK (ALT+O).

3. To read a note:

• Select its line and click Detail (ALT+D). Click Close (ALT+C) to return to the Order Notes list.

• Click Close (ALT+C) to return to the Review and Transcribe list.

An order does not have to be transcribed to save appended notes.

• Sign the transcriptions:

1. Click Sign (ALT+S).

2. Type your clinical key when prompted.

3. Click OK (ALT+O).