Noting orders VERY late...legally, what happens?

[nervousnurse]

UGH!!! The other day, I found new orders on my patient NINE HOURS after they'd been written. I'm sure I don't need to explain ALL the reasons I never saw the chart---you all already know

What ticks me OFF is of course, the patient could have been affected negatively,

AND.....what about if I were to go to court? I can imagine the lawyer would do everything

to discredit me...

(laywer)."NINE hours???......you didn't see these orders for NINE hours?".....

(me) "but, first PT had it, then the RD had it, then speech had it, then OT had it, then the physicians had it, then the case managers had it......then the chaplain had it...."

(Lawyer) those are not valid reasons.....YOU were still that patient's nurse!

(Me) Yes; however, I also had MANY other patients and I ran all day! There's no way I

could know about those orders without someone TELLING me! Is it my fault we don't have a more ORGANIZED system, perhaps, COMPUTERZED orders!!???

(Lawyer) Again, You were the nurse, it was YOUR responsibility

(Me) Thanks, you have now confirmed my choice to work at Walmart!

But seriously, I want to know the LEGAL ramifications of this. Where do I start? Would it be under my state's Nurse's Practice Act??? Looking back, I wish I had done what I usually do----COVER MYSELF in my Nurse's Notes!!!!!---I *wish* I had written "new orders received and noted late due to several ancillary personnel had possession of the chart throughout the day."

[shiccy]

I personally thing it's downright rude and should be a crime for MD's to come through and not say anything to the RN. I'm glad I work nights because I don't see many docs, and I'm the one writing orders typically however I just changed floors and was on days for a while to see how things were done. You don't have to tell me how annoying it is to have to play hide and go seek with your freaking charts! This being said, many of OUR docs tell us what they're going to write for. This does two things. If they DON'T write for something and you ASKED them what they wanted, then you can chart it FOR them. This has happened many times to me, and I have no problem with it, plus you DID ask them so even though they forgot, you don't have to call them back so they appreciate it.

Please note that I do fortunately have time to ask the docs what they're ordering b/c I am in an ICU, so we can see the docs a bit easier ... made it a bit harder when you have patients in three halls, not being able to see anybody in either other hall if you're not in it.

[nervousnurse, ASN]

after reading more responses, (thanks again!), I think in our facility, the sign on the patient's door is the BEST way for us! What a GREAT idea!!! There would be absolutely NO doubt, and I could go and find that chart! When I said the charts are sometimes gone for HOURS, that was true, HOWEVER, if we had to, we CAN go to the meeting and peruse the chart if needed.

Another order I found a couple hours late was not *STAT* by any means; our secretary or the doc would've told me....(I hope!)

However, one was for NEW pain meds and I'm sure the patient would've appreciated getting them EARILER when it was written! (she was okay, because I still gave her Oxy I-R every three hours on the DOT, and her Xanaflex Q6), the NEW order was to add Oxy 10mg CR BID......as I said, I'll bet she would've LOVED to have that earlier!!!!

The other chart I saw NINE HOURS later was for a change in respiratory meds for a COPD patient---luckily, the order was to change from Q4 nebs to "change to PRN for wheezing/ SOB". Thank goodness it didn't hurt her to keep getting them on the Q4 schedule..... :)

[BabyLady, BSN, RN]

Thank you for all your replies, I really appreciate it and I agree with everything that everyone said!

Where I work, the way we deal with charts is TERRIBLE on certain days. The charts DO leave the nurses' station for a couple HOURS because they have meetings to discuss all the patients and everyone needs certain papers to fill out, so the charts are just GONE. This is also terrible because sometimes we have questions that only the chart can answer---labs, progress notes, etc......UGH!

Me thinks I'm going to chat with our risk manager about this......I still cannot believe the charts leave the floor for HOURS----!!!

Our physicians have meetings every day regarding patients.

Still...the charts NEVER leave the units.

Physicians also keep their own notes on patients...mainly because that is how they bill..so you can bet your bottom dollar that they know what is going on with every one of them.

[SandraCVRN]

we used to have a sign the doctors would turn over that was red that said "new orders" , it hung outside the patients room . Also- If someone took the chart they had to leave a not - chart is with " ____" . It really is not OK to have the chart gone for 8 hours - its a safety issue!

We had flags outside the room, green for new orders, red for stat, yellow meant the unit clerk put the orders in and we needed to note them.

[steelydanfan]

That is crazy! Do you have a chart sign in/sign out book at least that way you know where the chart is? If not they should print out duplicate copies of labs or whatever they need to take with them.

Just my take and suggestions:

Every chart in the US has tags for orders, stat orders, and orders that need to be noted.

Rule 1. NO ancillary personal can leave with a flagged chart without checking with the charge nurse. Takes maybe 15 seconds.

Rule 2: A hospital policy that states that if stat orders are not personally delivered by the DR. to the charge nurse, pt's nurse or unit clerk, there is no liability to be found of the RN caring for the pt.

[MomRN0913]

That is why nursing management should arise from that chair in their office and do rounds with the MD.

Then, even if they were too lazy to note off the orders it could be brought to your attention that the orders were there to begin with to deal with in a timely manner. And also come up with a way to alert depts to LEAVE THE CHART ALONE due to orders on the chart to deal with!

It really should become mandatory for all nursing management to meet on the floor hours to keep their jobs. That way they really get & understand what is being asked of their nurses. It would really help.

Assuming a little are you? After being on both sides of the spectrum, and reently, I don't agree with this totally. I recently went from IU bedside to LTACH manager. IN my new faciltiy we have a charge nurse who does everything for these patients. Which I dont believe in, which I am slowly changing. I am learning this new facility so on the da there is no charge nurses I help out a little and I was asking questions. Well, the answer was "I don't know, then charge nurse does it." That's not good. They should know how to take off orders, what dr's to call for what abnormal result, but they have no clue. No critical thinking, just task oriented. Certain orders should be questioned by the MD by the primary nurse. Hey, I know staff nurses are overloaded. But so are Nurse Managers, and your perception of them just sitting in the chair is wrong. I work longer harder hours as a nurse manager without breaks than I did as a bedside nurse. And I don't get to leave my work at work, it follows me home on the weekends and after hours.

I as a manager do rounds with Dr's. I look through some charts when I am lucky enough to get a chance.

You can miss an order. That's why myf acility has 12 hour chart checks. it is possible and a legitimate mistake. But I know there are certain points in a shift, a primary nurse can check her charts. Not just once. I worked in an ICU where the charts were constantly hoarded. So you know what I did? I asked the Dr, or the RT, or PT to just take a glance at the order sheets while the charts were in their hands just ot make sure I didn't miss an important order. Some orders can wait, some are more important. And when they are, the Dr's in our facility are actually good enough to tell you there is a stat or an important order waiting for them.

Your not going ot court for this. And the patient was harmed, so why would you think that? wehat would they sue on the grounds of if the patient wasnt hurt?

Relax, it's OK. You live and learn. Don't be afraid to took at a chart while it is someone elses hand.

[cfeckers]

How do you "note" computerized orders? I just recently left a large 400 bed hospital that only "confirmed" medication orders in the computer against the original order placed in the computer by the physician. The order would go straight to the pharmacy, so essentially you are double checking that the med order came back from the pharmacy system correctly. We had no way to "note" orders that are not written. The small hospital I just began working for is printing out all of the computerized physician orders and "noting" them then scanning them back into the patient record which poses some issues in my mind for the security of the record as scanned items cannot be encrypted for saftey.

Can anyone give me any ideas how to tell this rural small town hospital that they don't have to note orders in the computer? Does anyone know where I can find the documentation to prove this? I have looked everywhere I can think of including my own nursing board and my old employer.

Thanks for any info!

[LouisVRN, RN]

Ughh...this is one of my pet peeves - from another chart nazi. Can you ask the unit secretary to make a copy of the orders as she enters them if you have a pt with a lot of consults and you know the chart will be off the floor. Like another poster said I ensure that i look through my charts at least once every couple hours to ensure that there have been no changes. I work nights so thankfully I am able to keep my charts with me by the computer I'm working at, although sometimes I'm shocked to see a doctor has come, written orders, and not done anything to mark the chart. It's not that bad though, I've found orders written from days previously that have never been noted or acknowledge. Drives me batty

[LTCangel, ADN, BSN, LPN]

In the hospital that I just left after 14 years, we had a very specific way of flagging and noting charts. It was taught to all the docs and new residents. Whwn they wrote new orders they would fold the page over and lay hte chart by the unit clerk's desk. The unit clerk would then put the orders in the computer, scan every order to pharmacy, then turn the color coded wheel on the chart to green and put it back in the rack. Green signified that the chart had an order that needed to be noted. Sometimes the doc would be too lazy to carry the chart to the unit clerk but they would still fold over the order sheet so we could tell that it had a new order. If I, as the nurse or the Charge nurse picked up the chart and saw that it had orders to be entered into the computer I could do one of 2 things. I would lay it next to the unit clerk or turn the wheel to yellow which meant that orders need to be entered in, or I would enter them myself. If there were stat orders the wheel was turned to red. If it was a discharge order the wheel would be turned to blue. Even more important though, a copy of each new order would be put into the pts slot in the med room so that the floor nurses could check the paper order against the new order that would pop up on their computer screen. If I was in charge, I would also call the nurse on the phone that we all had to carry and let them know that their were new stat orders or orders of high impotance such as giving blood. Orders would not be noted until all of the med orders, etc. were profiled onto the pt's electronic record. Once that was verified, the order would be noted and the wheel was turned to black and put back in the rack. We also did 24hr chart checks on night shift. Was this perfect? NO. Sometimes docs wouldn't fold over the page or they would put the chart back in the rack without letting anyone know they had written a new order, and it might be hours before it was found. As the floor nurse and the charge nurse I tried to scan each chart every so often to make sure no new orders had gotten past me. Most of the time though if a doc had written a stat order they would tell someone whether it was a nurse or the unit clerk. Sometimes though things just happen and you can't always catch everything immediately. You can only do the best you can and try to correct any mistakes that may have occured. I have just started a new job in LTC(it was time for me to leave floor nursing!) and I just beginning to learn the procedures of the facility. But there is only one doc for all of the residents who comes in once a week to do rounds on the residents, unless there has been a new admission or a resident has a change in condition that he needs to assess. The rest of the time he is called for telephone orders. This is def. less confusing than having 20 different doctors in a chart in one day!