annoying little thing some of our docs are doing

[psu_213, BSN, RN]

That thing would be writing orders without seeing the patient. The doc looks at the CC and perhaps the triage note (although based on some orders, the latter does not seem like it always happens) and then write orders for it before they assess the pt. One case was a 30 something year old male with a CC of upper abd pain. Doctor orders: IV, abdominal labs, urine, cardiac monitor, chest Xray, and troponin. I go in to do my assessment (still before the doc is in there) and it turns out the guy has a hx of GERD and ran out of his PPI.

It has happened in other circumstances too. One time I thought the doc had already been in the room so I carried out the orders including starting an IV (which meant I had to explain why the doc thinks the pt needs an IV even if he hasn't evaluated the pt). While I'm in the middle of lining him, the doc comes in to the room for the first time. I finish up. As I'm leaving, the doc tells him there is nothing we can do for him since he has been seen at our ER multiple times for the same CC (another abd thing). Patient gets upset since he has been stuck for no reason for an IV that was in 5 minutes.

Docs who do this are trying to save time. Since docs are judged on their times (i.e. time it takes them to make a disposition) it makes sense. However, someone has decided to judge nurses based on customer service scores, and putting in IVs for no reason is decidedly bad for PG scores.

Anyone else deal with this?

OK, rant over...for now.

[emtb2rn, BSN, RN, EMT-B]

Yeah, we've been seeing this as well with a few docs. Doing it to make their times look better. Then not seeing the pt until labs come back. Mostly with young belly pains.

Very annoying.

[Sassy5d]

Orthostatics on every pt, regardless of cc.

Acting like they are 'God' and the only thing going on is the 1 thing that they need done on 1 pt. I'm glad you need to do a pelvic exam on someone with a vag discharge but my bil PE over here REALLY needs their heparin.

I too, enjoy having full battery work up ordered and pt going off to ct and doc hasn't seen them yet.

[RN58186]

I work in an outpatient clinic, one of our docs will write the letter to the family doc (I saw Mr X, I recommended this and that, he had no other complaints, return to clinic 6 months) before he even lays an eye on the pt. And gets decidedly annoyed when there actually IS something going on and he has to change the letter.

[M/B-RN]

The thing that annoys me the most is when they write orders, tell no one, and put the chart back in the cubbie, and then come back to ask why nothing was done. I check all my charts during my shift, but in order to keep things straight in my mind and not confuse patients, I check them right before I go see that patient, and sometimes I don't get to assess certain patients until 1-2 hours after my shift starts.

All I ask, is two seconds of your time to say "hey I wrote stat/routine orders for this patient" or at least flag the chart and place it somewhere visible because I have a lot going on!

[Guest343211]

Sorry, I just have to disagree with this practice. You really shouldn't make a plan or orders sight unseen. Call me crazy, but I think this is a major violation. It's one thing to get prelim info, review it, make notes or whatever, but how can you practice medicine without examining the patient for yourself?

[ROBJAX]

I too am dissapointed with Doctors or Resident Doctors that write orders based on the CC. Causing the nurse to appear to do things that aren't needed, when in reality she must explain and make the patient believe the doctor ordered it and Yes with out even seeing you the Patient. Often patients have multiple CC's or needs but the doctor only wants to address one or two CC per visit causing the patient to need to return for multiple visits, the patients then become angry with nurses and blame us for their dissatisfaction. In addition the doctors often want their nurse to complete a bit of their work for them. They want us to pend all of their orders (example: if we think the patient needs this or that, medication refills, immunizations, foot exams, Blood Pressure Check visits, Diabetes needs, GYN needs ETC., which ends up causing the nurse to spend more time than she is allowed with the patient and I say allowed because we are penalized too based on our time, (causing her/him to appear slow or inadequate) decreasing the Doctors time with the patient. The nurse is expected to greet patients, answer phone calls, collect vitals, room patients, collect vital information, pend orders, assist doctors with exams, conduct nurse visits, give injections, run all over the clinic to collect medications and or supplies needed, assist during emergencies, help other staff as needed, make appointments for patients, discharge patients. AND to top it off always smile and avoid appearing rushed while seeing a minimum of 20 to 25 patients a day, if there are nurse visits for that day it could mean 25 to 30 patients scheduled in a day. HELP yes you did go to school longer than us, and you are the Doctor, but where would you be without your nurse? SO Please treat us like we are people not robots!

[kaylasmommy]

In our ER we have chief complaint driven protocols in which we can order stuff based on the CC on behalf of the doc based on pt presentation. So often things (lab work, line, X-ray, EKG) are done before the doc sees the pt. we can also give certain Meds (ie nitro and Asa to a chest painer or nebs to a sob). If a pt is on the fence (not sure if doc is going to want full work up) we let doc see pt before we do anything. Sometimes the doc beats us to the pt but other times its a huge time saver. I don't really have a problem doing these things because honestly the lab work and X-rays and EKG are data collection that gives the doc a better idea of what's going on.

Also it's a time saver because while you're getting the pt settled in and doing their vitals you are also doing things that you know are going to be ordered anyway thus saving you a second round with the pt.

J

[Guest343211]

In our ER we have chief complaint driven protocols in which we can order stuff based on the CC on behalf of the doc based on pt presentation. So often things (lab work, line, X-ray, EKG) are done before the doc sees the pt. we can also give certain Meds (ie nitro and Asa to a chest painer or nebs to a sob). If a pt is on the fence (not sure if doc is going to want full work up) we let doc see pt before we do anything. Sometimes the doc beats us to the pt but other times its a huge time saver. I don't really have a problem doing these things because honestly the lab work and X-rays and EKG are data collection that gives the doc a better idea of what's going on.

Also it's a time saver because while you're getting the pt settled in and doing their vitals you are also doing things that you know are going to be ordered anyway thus saving you a second round with the pt.

J

These are like protocol orders, but I was not aware that was what the OP was talking about.

Eg, pt comes in with severe angina, SOB, etc, standard protocol orders can be in place for diagnostics, which nurse should be moving on. That's been done in emergency for well over 30-50 years--although standardized orders may not have been written. It was more like the nurses worked with the docs and knew what was needed/anticipated, and they just worked together like a machine. The litigiousness of society changed that, so in order to cover butts re: tx and financial reimbursement, protocol Rxs, based on known conditions and algorithms, are to be established.

But no physician should be writing further tx or dx orders beyond that without actually taking the time --and not just a peek through the door--to see the patient.

Today that have all kinds of people that are investigating this kind of thing. There are even doctors that come in feigning to be patients. They evaluate how things are going. So, in one way or another, these docs or pa's that may be doing this kind of thing are going to get kicked in the butt if they continue practicing in the way in which the OP was talking. The pt-spies or some such situation will jump up to bite them and the hospital in the orifice in due time.

Bad practice.

[VICEDRN, BSN, RN]

Are you kidding me? I hate when doctors insist on seeing patients before writing orders. All belly pains are getting protocols. Why bother waiting til they tell you about it in person? They already told the paramedic, the triage nurse, the primary nurse...it just slows everything down.

[psu_213, BSN, RN]

Are you kidding me? I hate when doctors insist on seeing patients before writing orders. All belly pains are getting protocols. Why bother waiting til they tell you about it in person? They already told the paramedic, the triage nurse, the primary nurse...it just slows everything down.

I have also seen it when the doc writes a whole bunch of 'protocol' orders before seeing the pt, then sees the pt and decides to cancel the orders.

[VICEDRN, BSN, RN]

I have also seen it when the doc writes a whole bunch of 'protocol' orders before seeing the pt, then sees the pt and decides to cancel the orders.

Fine. Let them cancel them. It's still worth it for the more than 9 out of 10 orders that aren't canceled. Seriously, every who doesn't have chf or renal failure and has a blood sugar of 500 or more in triage per glucometer is getting at least a liter fluid bolus.