9.21:
Types of Reports III: Telephone and Verbal Reports
Telephone orders are placed when a healthcare provider verbally communicates therapeutic instructions to a nurse over the phone.
For telephonic orders, oral confirmation is obtained from the practitioner to ensure proper documentation.
It is vital to document the order details, including time and provider's name, and obtain a signature from the practitioner for verification.
The phone calls are recorded in the medical record for accuracy checks and to notify relevant personnel.
The orders are read back to the healthcare professional and documented as TORB. Here, TORB stands for telephonic order read back.
A follow-up is carried out with practitioners for any changes, documenting patient responses and reviewing orders for accuracy and clarity.
Adhere to organizational policies for telephonic order documentation.
In contrast, verbal orders are given when a healthcare provider provides therapeutic instructions to a nurse in person while they are close to each other.
Verbal orders can lead to misunderstandings or errors due to accents, dialects, or drug name pronunciations.
It is generally recommended to avoid relying on verbal orders, except in emergencies.
9.21:
Types of Reports III: Telephone and Verbal Reports
Telephone and Verbal Reports in healthcare settings are two communication methods for conveying therapeutic instructions from healthcare providers to nurses or other healthcare staff.
Here's an overview of each type:
Telephone Orders
- Usage: Telephone orders are used when a healthcare provider needs to communicate therapeutic instructions to a nurse or other staff over the phone. It often happens when the provider cannot be physically present.
- Confirmation and Documentation: Oral confirmation is obtained from the provider to ensure the accuracy of the order. Essential details like the order content, time of the call, and the provider's name are documented. A signature from the provider is required for verification purposes.
- Recording and Accuracy Checks: These phone calls are recorded in the medical record. The process involves reading back the orders to the healthcare provider for confirmation (TORB – Telephonic Order Read Back).
- Follow-up and Review: Regular follow-ups with providers are necessary for any changes. Patient responses to these orders are documented, and the orders are reviewed for accuracy and clarity.
- Organizational Policies: Adherence to specific policies for documenting telephonic orders is crucial to maintaining consistency and legal compliance.
Verbal Orders
- Usage: Verbal orders are given in person by a healthcare provider to a nurse or other staff. These are typically used when the provider is physically present and can directly communicate the instructions.
- Risks: Verbal orders carry a higher risk of misunderstandings or errors due to factors like accents, dialects, or similar drug name pronunciations. Miscommunication can lead to significant medical errors.
- Limitation and Emergency Use: It's generally recommended to avoid relying on verbal orders due to the increased risk of errors. Verbal orders are more acceptable in emergencies requiring immediate action when there's no time for written communication.
- Documentation: Despite being verbal, these orders should be documented as soon as possible for record-keeping and to ensure accuracy.
Summary:
Telephone and verbal reports are vital in healthcare for urgent medical orders but pose risks for accuracy. Stringent documentation, confirmation protocols (e.g., TORB for telephone orders), and policy adherence are crucial for patient safety. In non-emergencies, written orders are preferred to minimize errors.