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A physician’s order is required for medical/surgical restraint and behavioral management restraint use. Written or verbal orders for initial or continued restraint use are time limited. Behavioral management restraint use requires a physician’s face-to-face assessment within one (1) hour of initiation. D. WRITTEN ORDERS Written orders must be legible. Print must be large enough to reproduce easily by fax or copy. Abbreviations may not be used for medication names. All other abbreviations must conform to the approved abbreviation list. (4) Orders must be written with pens/devices capable of transferring legibly through multiple copies. Felt tip pens may not be used. (5) Changes to existing orders must be made by way of new orders. Existing orders may not be corrected/scratched over. (6) All admitting orders must include patient allergies. (7) All physician orders must be accompanied by a legible identifier consisting of the physician’s assigned four-digit dictation number, in addition to the prescriber’s signature. (05/06) (8) All orders, to be complete, must contain date written, medication name, dose/strength, quantity or duration (as appropriate), route and frequency. Direct admissions must be accompanied by physician orders. (10) Patients undergoing a change in level of care must have current orders reviewed and signed. The patient’s full name must be documented on the order sheet prior to order being written. Physician must attempt to use Orlando Regional order sheets or office letterhead for direct admissions. (13) Medication Orders Abbreviations may not be used for medication names. All other abbreviations must conform to the approved abbreviation list. Orders should include height/weight/allergy/creatinine where applicable. July 2009 Medical Staff Rules & Regulations 9
1. Chemotherapy orders should include patient height, current weight, and body surface area, where applicable. 2. Pediatric orders should include patient weight, and mg per kg/dose. All PRN orders must include indication and dosing schedule. Medication orders should not contain trailing zeros (i.e. 5 mg vs. 5.0 mg), should include a pre-decimal zero where applicable (i.e. 0.5 mg vs .5 mg), and units should be spelled out (i.e. Units vs. U.). (14) Each individual order must be rewritten postoperatively. “Resume pre-op orders” or similar notation is not sufficient. (07/05) E. PROHIBITED CONDITIONAL MEDICATION ORDERS (01/07) Any medication order that is conditional upon another prescriber’s approval is not allowed. 4. CLINICAL OBSERVATIONS CONSULTATIONS The consultation request shall include the reason as stated by the attending physician, dentist, or podiatrist. The consultation report shall reflect evidence of a review of the medical record, actual examination of the patient, pertinent findings, opinions, and recommendations. Refer to "General Standards of Patient Care" for cases in which a consultation is required. PROGRESS NOTES All medical staff progress notes shall be dated and signed by the physician, dentist, or podiatrist who recorded them and will give a pertinent chronological order of the patient's course in the hospital. Whenever possible, each of the patient's clinical problems will be clearly identified in the progress notes as well as results of tests and treatment. They shall be recorded at the time of observation and written to permit continuity of care and transferability of the patient. Progress notes shall be written at least daily, except in Rehabilitation Units where inpatients will be seen and progress notes recorded at least three times per week. For stays of less than 48 hours, a final progress note will be made upon discharge. (3) There must be evidence on the progress notes of the medical record that includes justification for the use of special procedures. Special procedures that require special justification include the following: July 2009 Medical Staff Rules & Regulations 10
Page 1 and 2: ORLANDO HEALTH MEDICAL STAFF RULES
Page 3 and 4: GENERAL STANDARDS OF PATIENT CARE A
Page 5 and 6: Unexpected or unexplained deaths du
Page 7 and 8: First incident: Second incident: Th
Page 9: Registered nurses, advanced registe
Page 13 and 14: CONCLUSIONS DIAGNOSES No abbreviati
Page 15 and 16: CONSENTS The medical record shall c
Page 17 and 18: The medical record of an ambulatory
Page 19: ALLIED HEALTH PERSONNEL Each medica

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