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Diabetes Educators Calgary Charting Guidelines

Verbal / Phone Orders

Verbal / Phone Orders

Prescribers are encouraged to enter orders directly into Connect Care, if possible. Nonetheless, there may be occasions when that is impractical, and a delay might adversely affect patient care. In those circumstances, educators may receive verbal or phone orders from a prescribing provider.

Please see this page for information specific to insulin.

See below for documention for anti-hyperglycemic agents other than insulin (e.g. metformin, GLP1, SGLT2i, etc) 

Medications other than insulin

“Insulin Instructions” should not be used to chart dosage changes for medications other than insulin. This is a system-wide feature, and is built for insulin only.

Use “Medication Review”

  • For RDs this is under the "Nutrition Care" tab
  • For RNs this is under the "Rooming" tab

 

RDs require an order

RDs are permitted to receive and document a verbal or telephone order from a prescriber. The order must indicate the patient specifically. The order is read back to the prescriber to ensure accuracy.

There may be charted instructions, indicating a timeframe or tolerance conditions, e.g. "increase by 500 mg per day, each week, if tolerated".

Step 1 - Remove old dose of medication

  • Under Medication Review, click the red X at the right of the medication dosage being changed.
  • Choose Discontinue in the pop-up window.
  • Reason = Dose Adjustment
  • Click Accept
Dose Adjustment

Step 2 - Add new dose

  • Use the Add Order window at the bottom of the chart
  • Enter the medication and press Enter
  • Select the medication. Do not pick "Clinic-Administered Medications". Use the Database tab, if the medication does not show up under Preference List or Facility List. 
  • The order shows up at the bottom right of the chart. Click it to open up the details window.
  • Document the new dose, etc. Use "Patient Sig" to indicate any free text instructions.
  • Accept.

Step 3 - Sign the Order

  • Click Sign Orders at bottom right.
  • In the window that opens:
    • Order mode = "Telephone with readback" or "Verbal with readback"
    • Authorizing provider = prescriber
  • Accept

 

The authorizing provider will receive an In Basket message to co-sign.

Sign order