Written patient orders

Standard COP.2.2 of the Joint Commission International (JCI) is about “Those permitted to write patient orders write the order in the patient record in a uniform location”.

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Each patient care plan includes written orders by individuals qualified to order  and record patient orders, for example diagnostic tests orders for laboratory testing, orders for surgical and other procedures, medications orders, nursing care orders, and nutrition therapy orders.

A uniform location in the patient’s medical record or on a common order sheet which is then transferred to the patient’s medical record periodically or at discharge, facilitates understanding the specifics of an order, when the order is to be carried out, and who is to carry out the order as well as creates easy accessibility to the orders so that orders can be acted upon in a timely manner.

All the four (4) requirements (MEs) of the JCI Standard COP.2.2 will be fully met if the hospital staff are aware and practice what is contained in a hospital policy which among other policy statements also states policies on which orders must be written rather than verbal, which diagnostic imaging and clinical laboratory test orders must provide a clinical indication/rationale, if there any exceptions in specialised settings, such as emergency departments and intensive care units, the staff member who is permitted to write orders and where orders are to be located in the patient’s medical record.

Health Information Management (HIM) / Medical Records (MR) practitioners working in a hospital must be aware and knowledgeable that his or her medical records in his or her custody and care contain orders by individuals qualified to do so.

Orders will be found in all medical records regardless of the type of hospital they work at, whether or not his or her hospital had acquired JCI accreditation status or one that is seeking JCI accreditation status or it is one that is not seeking JCI accreditation status at all.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA