Final answer:
Taking a verbal order in a healthcare setting involves receiving the order, documenting it using SOAP or SBAR notes, reading back the order for confirmation, signing and dating the documentation, and then carrying out and monitoring the patient's response to the order. Verbal orders must always be documented to ensure patient safety and maintain accurate medical records.
Step-by-step explanation:
The process for taking a verbal order and documenting this communication in a medical or healthcare setting often involves several key steps for ensuring accuracy, patient safety, and compliance with institutional policies. In general, a healthcare professional would:
- Receive the verbal order from an authorized prescriber, such as a physician or nurse practitioner.
- Immediately document the order in the patient’s medical record. This is often done using the SOAP notes format (Subjective, Objective, Assessment, Plan) or, alternatively, the SBAR format (Situation, Background, Assessment, Recommendation) which is a structured method for communicating critical information that requires immediate attention and action.
- Read back the order to the prescriber to confirm its accuracy. This read-back should also be documented.
- Sign (or initial) and date the documentation to authenticate it and include the prescriber’s name.
- Carry out the order as prescribed.
- Monitor and document the patient’s response to the order.
It is important to note that this documentation does not occur in informal records such as a patient’s diary; it must be part of the formal medical records. The option 'Verbal orders are not documented' is factually incorrect because verbal orders must always be documented to maintain a legal and clinical record of care.