UAMS inpatient beds, Surgical Services, Short Stay Unit, Radiology, and Emergency Department are supported by a computerized electronic medical record, EMR.  Physicians are responsible for entering their patient orders into CPOE.  Nurses may enter emergency verbal or telephone orders only if the physician does not have access to CPOE.  Physicians are to provide their HBO # (a four-digit number) when giving verbal or telephone orders.  The nurse confirms the HBO # in the electronic record when entering orders.

The nursing staff performing clerical duties manages orders in the following manner:

1. Monitor all printers for New Medical Order Sheets and promptly notify the appropriate nurse to initiate 
   immediate action on all STAT and NOW orders.
2. Route all lab specimens with the Specimen Transmittal Sheet to the laboratory.

3. Initiate action on each order:

1. Generate the appropriate EMR documents.
2. Notify consulting departments of new consult orders.
3. Further notification measures are carried out according to unit standards.
4. To ensure patient safety, licensed care providers will implement the most current order in the following categories:

• Diet
• Activity
• Vital signs
• Primary maintenance IV fluids

4. If orders are transcribed by a  PSC:

1. Charts containing transcribed orders are to be flagged to alert the appropriate nurse to crosscheck the written orders against the transcribed orders for accuracy.
2. Charts are flagged by raising the order above the level of the hard back of the chart for a visual cue.

5. The nurse who acknowledges and/or crosschecks EMR orders must write initials and last name, title and time near the EMR order.
   first and last name, title, time, and date near the physicians written order.
6. Licensed care providers may complete any duplicate orders previously implemented or no longer applicable and previous orders in the following categories in the electronic chart:

• Diet
• Activity
• Vital signs
• Primary maintenance IV fluids

7. Questionable orders are to be validated with the physician by the nurse caring for the patient. 
   (Addendum M.1).

DOWNTIME MEDICAL RECORD

To ensure the safe and efficient processing of written orders directing patient care, the following steps 
outline the duties of Nursing Department personnel during times when EMR is not available.

The nursing staff performing clerical duties transcribes written orders in the following manner:

1. Review all charts for STAT or NOW orders, and promptly notify the appropriate nurse to initiate immediate action.
2. Fax all orders and requests to the appropriate department.
3. Initiate action on each written order.

1. Fill out the appropriate requisitions and forms.
2. Notify the hospital departments involved.
3. Transcribe and initial medication orders on Medication Administration Record (MAR).  

          *ICU’s document medications on the ICU flowsheet.

4. List treatments and procedures to be performed on the Treatment   Kardex. (Further notification measures are carried out according to unit standards).

4. If orders are transcribed by a  PSC:

1. After reviewing or transcribing the orders, the  PSC enters a first initial, 
   last name, title, and time directly below the last order written near the left 
   margin.
2. Charts containing transcribed orders need to be flagged to alert the appropriate 
   nurse to cross-check the orders for accuracy.
3. The nurse who transcribes and/or cross-checks transcribed orders for accuracy enters first initial and last name, title, and time  near the PSC/PSA signature.

5. Questionable orders are to be validated with the physician by the nurse caring for the patient. 
   (Addendum M.1)

6. When EMR comes back up, MD orders have to be entered back into EMR.

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