Role of the NCU

Coordination of communication is the focus of the Nursing Unit Clerks job. They must determine who need to know what information and how quickly that information need to be conveyed. Physicians record all directives for the Patients care on the Physician’s Order Form which is contained in the patient’s chart. The physicians order form is used as a means of communication between the physician and the nurses, it becomes the permanent record of all patient care prescribed by the physician during the patients stay in the hospital. The nursing unit clerk is responsible for completely clerical duties necessary to see that the order gets carried out. This includes notifying the person or department responsible for carrying out the order, completing the paperwork or computer entries necessary. This is referred to as “processing orders”. The term “CPOE” is a computerized physician order entry. The components of a physicians order is 1. date the order was written 2. time the order was written 3. physicians signature. The types of orders are 1. standing order - meaning it stays in effect until the patient is discharged or until another order is written to change or discontinue to order. Examples are diet orders, medication orders etc. 2. short-series order - meaning it is ordered during a specific time frame or to be carried out a specific number of times. Examples are “full fluids for 48 hours” or “CBC daily x 7 days” 3. One-time order - meaning it is only carried out once. Examples are lab orders, such as chest xray etc. When processing the physicians order form, you would indicate what action has been taken to complete the order by using notations in red ink. The idea behind notations is to give as much information as possible, while writing as little as possible using abbreviations and acronyms.