A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?
a. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back.
b. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN, read back.
c. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.
d. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN.
C
The nurse receiving a TO writes down the complete order or enters it into the computer as it is being given. Then he or she reads the order back to the health care provider, called read back, and receives confirmation from the person who gave the order that it is correct. An example follows: "10/16/2011: 0815, Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Knight/J. Woods, RN, read back." VO stands for verbal order, not telephone order. The doctor's name and read back must be included in the chart entry.
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