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Medication orders - lc
Posted: Sep 22, 2011
If a doctor does not say mg when dictating medications, should we add it?
I type what the physician says never had a problem doing that - nm
[ In Reply To ..].
I add it - They expect you to
[ In Reply To ..]:D
Nope, never have added - 1mt
[ In Reply To ..]If they don't say it, I don't type it. Most medications may be mg, but not all are, mEq, IU, mcg, g, etc. I'm not going to add in what the doc should have said and potentially make a major mistake.
I totally agree and additions where I work are counted on QA scores just - like omissions are
[ In Reply To ..].
If it's not mg, then put what "it" is - Add It
[ In Reply To ..]Don't just leave the number there all by itself.
Oh my...bad advice to add something that is - NOT dictated.
[ In Reply To ..]Better off flagging than adding it yourself. Cover your butt at all times. You cannot be wrong if you do not transcribe what is NOT dictated. On the other hand, you will ALWAYS be wrong if you ADD something.
I add stuff all the time - when the doctors leave it out
[ In Reply To ..]But then, my "QA" is the doctors themselves and they expect me to fill in their blanks when it is obvious what was left out.
Patient Hazard! - Really
[ In Reply To ..]Are you SERIOUS? The doctor you work for depends on "your" opinion? QUACK.
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