Verbal Orders

[ktliz]

This has become a focus of management in our unit recently. Previously (as in, before I was off orientation), nurses regularly took verbal orders from providers and entered them into the computer as such. Management brought it to our attention that hospital policy only permits verbal orders in the case of an emergency where the physician is physically unable to enter the orders in the computer (e.g. when they are in the middle of a sterile procedure).

Side note: We are also to encourage providers to log onto their laptops from home, if possible, to enter orders rather than take phone orders. Of course, 9 times out of 10, the provider (probably snug in bed at 0300) will say, "I'm not near a computer," and then we are permitted to take phone orders.

But phone orders aren't the issue. The issue is when I have to hunt down a resident to put in orders for the 3 boluses and Levo gtt that I already hung on a patient (with verbal orders, of course), because I'm not allowed to actually enter the orders myself. Management says that taking verbal orders puts us at risk of "acting outside our scope" and that we need to "protect our licenses" because "physicians will turn on you in an instant." I feel my license is at greater risk if the orders never get put in, and waiting for them to get put in puts my patient at risk.

I'm a new nurse, and this has been an issue in our unit for as long as I've been here (over a year.) I just don't know how it is realistically supposed to work. *Supposedly* these same providers (residents, mostly) follow policy when they are on other units, and only give us verbal orders "because we let them."

Is this an issue anywhere else? Is it unreasonable to expect a provider to have a laptop attached to their hip while covering the unit? When is it truly appropriate to take a verbal order?

[ICUPrincessNurse]

It's not unreasonable for a computer to be close by if they're on call covering the unit. When we went all computerized we got multiple computers at each alcove, extra COWs and extra desktops all over the place. They should understand that if they're on call for the ICU a computer should be close.

Plus, theoretically, if your patient is sick enough to need 3 boluses and a levo gtt- your resident should be close. Like, at the bedside close.

That said...We have a few attendings who still dictate their notes on principal and whom I'm certain are physically unable to enter an order. I'm not saying they get TORB'd a lot....but. For the most part though...these guys are rounding with residents who put in the orders and it's basically a non issue.

[loriangel14, RN]

It may greatly depend on the policy and procedures of where you work. In my workplace verbal and telephone orders are no issue.We transcribe it onto an order sheet and after a cosign we carry out the order.

[meandragonbrett]

It's not nursling's job to police providers and orders. If they tell me they aren't near a computer...how are we to know different?

Some hospitals are on a warpath about this and strictly forbid it and others are much more laid back. Your management team needs to go to the medical staff to solve the issue. It shouldn't be your concern at the bedside.

And the "losing your license" scare tactic is nothing but a sign of a poor management team IMHO. They like to use this to encourage the flock to follow their directives and not question or seek our rationales. Look at your state's BON hearings and you'll see what people lose their license for or get disciplined....it's generally NOT the things you see members on here and your management telling you that "could" happen.

Just be a PRUDENT nurse and practice mindfully and you have nothing to be worried over.

[MunoRN, RN]

It's not unreasonable for a computer to be close by if they're on call covering the unit. When we went all computerized we got multiple computers at each alcove, extra COWs and extra desktops all over the place. They should understand that if they're on call for the ICU a computer should be close.

Plus, theoretically, if your patient is sick enough to need 3 boluses and a levo gtt- your resident should be close. Like, at the bedside close.

That said...We have a few attendings who still dictate their notes on principal and whom I'm certain are physically unable to enter an order. I'm not saying they get TORB'd a lot....but. For the most part though...these guys are rounding with residents who put in the orders and it's basically a non issue.

It's important to remember that non-teaching hospitals are a very different situation. It's very unlikely that the MD is going to be hanging out at the bedside just because you're giving levo boluses in a non-teaching hospital. I've worked at a teaching hospital ICU where, between the Residents, PAs, NPs and attendings there were at least one per every 4 or 5 patients, in the 2 non-teaching ICU's I've worked in it's about 20 ICU patients for the one ICU doc, and that Doc is also does all of the inpatient pulmonologist rounding, in which case depending on CPOE only is very problematic.

While it may be safer for Nurses to never write verbal orders, it's certainly not safer if you've been giving STAT meds and the order never gets entered, now you're giving meds with no order, instead of just giving meds with a verbal order.

[ktliz]

At night, one resident covers our 20 beds, sometimes plus an intern. Oh, and the tele-intensivist "babysitter" (who I am thankful for, but they are mostly hands off.)

Oh, the other thing I personally freak out about is pushing narcs without scanning them first. I hate pulling them from the Pyxis (with or without an order), "just in case," e.g. for a procedure, CT scan, or MRI. So afraid I will lose or forget to scan something and be accused of diverting!

[calivianya, BSN, RN]

There are a lot of lazy physicians at my work who will give verbal orders when they are standing right next to a computer because they don't really want to be bothered. It's extremely tiresome.

I find I put in more telephone orders - we don't have an intensivist and there are no residents, and actually there are no physicians at all on nights, so I'm always calling the physician for everything. It is really aggravating when I have a patient going bad, the operator pages the physician, and the physician takes half an hour or longer to call back. I think just about everyone on my floor has technically practiced medicine without a license at some point if it's necessary to save a patient's life and no one can get a hold of a physician to write an order. There have been times where meds have definitely been given without an order (not by me, not yet at least) and you have had to get an order after the med was given from whatever physician is willing to write it. It makes me nervous. I would love to be able to go somewhere that has a physician in house. I feel like that would increase my chances of being able to get an order when I need it.

[cardiacfreak, ADN]

There are a lot of lazy physicians at my work who will give verbal orders when they are standing right next to a computer because they don't really want to be bothered. It's extremely tiresome.

I find I put in more telephone orders - we don't have an intensivist and there are no residents, and actually there are no physicians at all on nights, so I'm always calling the physician for everything. It is really aggravating when I have a patient going bad, the operator pages the physician, and the physician takes half an hour or longer to call back. I think just about everyone on my floor has technically practiced medicine without a license at some point if it's necessary to save a patient's life and no one can get a hold of a physician to write an order. There have been times where meds have definitely been given without an order (not by me, not yet at least) and you have had to get an order after the med was given from whatever physician is willing to write it. It makes me nervous. I would love to be able to go somewhere that has a physician in house. I feel like that would increase my chances of being able to get an order when I need it.

I had to do this last night, the patient was cool, clammy, obtunded, and pale. I checked the blood sugar and it was 20. Of course there isn't any hypoglycemic orders, I gave the 1/2 amp of d50 and had the patients nurse call to get the order. Why didn't somebody get hypoglycemic orders for a patient receiving insulin in the first place?

[morte, LPN, LVN]

I had to do this last night, the patient was cool, clammy, obtunded, and pale. I checked the blood sugar and it was 20. Of course there isn't any hypoglycemic orders, I gave the 1/2 amp of d50 and had the patients nurse call to get the order. Why didn't somebody get hypoglycemic orders for a patient receiving insulin in the first place?

yup, yup, yup!!!