Arkansas Long Term Care Administrator Practice Exam

What documentation is required after taking a physician's phone order?

1. A note on the back of the patient's chart

2. Recording in the physician's orders sheet

3. A verbal confirmation from the physician

4. Written consent from the patient

The correct answer is: Recording in the physician's orders sheet

After taking a physician's phone order, it is essential to record the order in the physician's orders sheet. This documentation serves several critical purposes in a long-term care setting. First, it ensures that all care team members have access to the most current and accurate information regarding a patient's treatment plan. Recording the physician's order promptly helps prevent any miscommunication related to patient care. Additionally, this practice helps maintain a clear and comprehensive medical record that can be referred to by healthcare staff at any time, thus supporting continuity of care. Moreover, documenting the physician's orders in the designated order sheet complies with regulatory requirements for healthcare documentation. Proper documentation is also a key aspect of legal accountability, ensuring that there is a formal record of the orders given and the instructions intended by the physician. In contrast, simply noting the order on the back of the patient's chart or relying on verbal confirmations does not meet the standards required for thorough and effective patient management, and written consent from the patient is not necessary in this context for a physician's order. Therefore, accurate recording in the physician's orders sheet is the best practice to ensure clarity, compliance, and effective patient care.