RN Review and Transcribe includes a few functions:
RN Review—Required for all inpatient and ED orders. RN only. Nurse has seen and signed off on a new order. Marked with R in Review and Transcribe list. Labels will print in the main ED for orders needed for the ED administration record.
Transcribe—Required for all orders. RN, PCIA, OA or OC. Requisitions, phone calls, and faxes completed as needed. Marked with T in Review and Transcribe list.
Annotate—Optional for any order. RN, PCIA, OA, or OC. Note attached to order. Separate signature required for each note. You can add a note without reviewing, transcribing, or verifying an order. Flagged with <N> in order summary view.
Orders written in the main ED treatment areas:
<ED order only>—All orders written in the main Emergency Department are flagged <ED order only>. These orders should only be used for emergency treatment in the main ED treatment areas. DO NOT sign off on or carry out orders intended for use only in the main ED unless the patient is actually in the main ED.
Inactivating ED orders automatically—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 with RN Review. Click (ALT+I).
Allergies updated in the ED—If the allergy record was updated in the ED, the order(s) must be resigned. MDs, NPs, PAs, and CNMs are authorized to resign. RNs and other staff, who are not authorized to resign, must acknowledge the "Allergy order from the ED" message and notify an authorized provider that the resign is required.
Pre-Admission—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.
Order Status in the UCM:
Pending (inpatient units)—At least one new order, but possibly more, needs to be transcribed. These orders may or may not have been reviewed by an RN.
Pending (Emergency Department)—At least one new order, but possibly more, needs to be reviewed by an RN.
<T>—All new orders have been transcribed. At least one, and possibly more, needs to be reviewed by an RN. Not used in the Emergency Department.
No Pending or <T>—Pending and <T> status is cleared only when all orders have been transcribed, reviewed by an RN.
See also: