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Procedures and Guidelines

Order Writing Policy

Categories: pgme ugme

Updated on:

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Purpose

To describe standardized procedures for order writing for undergraduate Clerks in the Doctor of Medicine program.

Principles

The Most Responsible Physician is responsible for orders written by learners under their supervision.  Patient safety and student learning are optimized by effective discussion and oversight of orders. 

Definitions

Clerk – Third to fifth-year students in the University of Saskatchewan Undergraduate Medical Education Program (UGME) are termed “Clerks”. During this program phase medical students focus on clinical learning activities in health care settings.

Order – Documentation in the patient chart by an authorized practitioner to require a diagnostic test, therapeutic procedure, medication, or other intervention for the care of the patient to be performed or administered.   

Most Responsible Physician (MRP) - or most responsible practitioner, generally refers to the physician, or other regulated healthcare professional, who has overall responsibility for directing and coordinating the care and management of a patient at a specific point in time.

Scope of this Policy

This policy applies to instances where Clerks registered in the Doctor of Medicine (MD) program at the University of Saskatchewan are involved in the care of patients, irrespective of the geographically distributed campus or site to which they are currently assigned.

Pre-Clerkship students cannot write orders for action on patient charts.

Related policies include:

Policy

Clerks are authorized to write all necessary orders for investigations and treatment of patients, after discussion with their clinical supervisor.  All orders must be written on the appropriate order form and must have clear documentation of agreement (e.g., countersignature) by the Most Responsible Physician or other approved prescriber (e.g., supervising resident) before being acted upon by Pharmacy or Nursing.  Where applicable, the Most Responsible Physician or supervising resident may confirm the order by phone.  Clerks must not change a physician’s orders without their approval.

Non-compliance

Instances of non-compliance with this policy should be brought to the attention of the Associate Dean, Undergraduate Medical Education and will be addressed through relevant UGME program and/or SHA policies.

Contact

Associate Dean, Undergraduate Medical Education
3A20 Health Science Program
306-966-6150