Nurses that write their own orders

[Kanani_Ikike]

Hello, all in allnurses.com universe. It's me again. I have a concern that I would like to share with you all and ask for your opinion.

At my new job, I am seeing a whole different culture of nursing that I have ever been used to. I work night shift in a rural hospital. And as we all know, there are times when calling the doctor is easier said than done. We have doctors that, when you page them, just won't call back. I understand that we don't need to bother the doctor for things that can wait until morning, but some things just can't wait. And I don't think it's right to be subjected to disrespect just for calling about our patients. As we all know, sometimes a patient can be fine all day and take a turn for the worst at night.

For instance, the other night, I had a pt. with a Foley cath. When I came on shift, this pt. was draining dark yellow, clear urine. About 2 hours into my shift, I noticed that the urine became bloody. Since this was something new, I called the doctor on call. First of all, he's obviousy not too thrilled about being on call. When I told him about the blood, which by the time he called me back, had increased with clots apparent, he said, "Well, you'll have blood with foley cath insertion." Then he proceeded to give me orders for labs to be drawn in the am. Well, I disagree, I've never had a patient bleed on me just due to the foley insertion itself. Of course, if it hasn't been inserted correctly (like in the neck of the bladder) or if it's been pulled down, THEN I can understand bleeding. But for the pt. to just start bleeding wasn't a good sign to me.

So, after I got that order, I continued to observe the pt. At first, it appeared that the urine was clearing of blood. Then after a couple of hours, I noticed that there had not been an increase in output at all. And I didn't see any urine draining in the tubing. So, this is when I start thinking that this pt. needed his catheter irrigated because it may be a clot blocking the urethra. The pt. started complaining of a burning sensation, but nothing like pressure and I didn't palpate any distention of the bladder at that time. So, I, again, page the doctor on call. Well this time, he didn't call me back. So, I paged him again. Still didn't get a call back. So, I contacted the house supervisor for assistance. Well, when I talked to her, she said, "Why do you need to contact him (the doctor) ?" I told her about the situation and she replied, "well, we can just write an order for irrigation, we don't have to bother him." I was like, "but we need an order for that" and she said, "well, I'll just tell him I told you to write it". Well, as you know, I didn't write that order on my own. So, when the smoke cleared, the patient was irrigated by the supervisor and he clot was cleared. He started draining urine again and lived happily ever after.

Okay, so this is where I am concerned. This is not the first time I've been told to write an order instead of calling the doctor. I've never heard of this and it makes me uneasy. Where I have worked the past, we had standing orders. I don't know why this facility has none. But since they don't have any, then I feel I should call the doctor for all orders. But they don't do this at this hospital. And there's more.

First of all, the supervisor letting the doctor get away with not calling back bothers me. Why do we have doctors if we can't call them when we are concerned about a patient? Why do they take call or even become doctors if they don't want to be bothered? Why not have standing orders for the simple stuff if you don't want to be bothered?

Secondly, I am very standoffish about writing orders without actually speaking to the doctor. I won't even write an order for Tylenol without talking to the doctor. This is because, #1, I'm not a physician. It's not in my scope of practice to write orders. #2, I am covering my behind. The first time something happens from me taking it upon myself to write an order, I know I'm going to be the one going down. But it seems like, in my facility, it is the norm for the nurses to write orders themselves. I understand that some of them are used to the doctors and feel that it's okay to do this. I just want to know if this is the norm in other facilities.? Do you all think I'm overreacting and being obssessive for not doing this? I mean, I understand not to call the doctor for every little non-urgent situation. But when I feel uneasy about something, you better believe I will call him in a heartbeat. Even if it means getting chewed out. What do you all think?

I just want to know if I'm doing something wrong by not going along with this practice? Comments and opinions will be greatly appreciated. I appreciate every post. I'm wanting to be a good nurse. I just would like to do the right thing, that's all. Thanks in advance for your replies.

[leslymill]

i am in long term care - i had my unit supervisor do the same thing - write order for a swallowing eval that the doctor had already said he didnt want - wrote the order, made a nursing note - then when the doc said definitely NO - she errored out the order and the note also - funny thing, those nursing notes are gone from the chart now - i didnt think it was right then and still dont now

That is falsification of records. Careful that kind of behavior will threaten licenses. Had an ER chart and order Visteril IV I called it to there attention and charted such. The supervisor came up rewrote the orders and made me look bad since I had charted about it already. I pulled the orders from the trash to protect myself . I doubt the ER gave the visteril IV, but they sure charted it.

[suanna]

Okay sterile irrigation costs $40.

Bladder Scan $300 to 600.

What is your choice considering the scan will probably indicate it needs to be irrigated. So another $40.oo

We use a bladder scanner several times a mos. It is floor equipment, just sitting in the clean utility room, and non-chargable. I'm not convinced of how accurate it is for residual after a small void, but it always picks up a FULL bladder.

[cassioo, RN]

We use a bladder scanner several times a mos. It is floor equipment, just sitting in the clean utility room, and non-chargable. I'm not convinced of how accurate it is for residual after a small void, but it always picks up a FULL bladder.

we also have a bladder scanner as floor equipment but if the patient is an outpatient you can charge for bladder scanner use x 1. I think ours is pretty accurate when used correctly which ours is hard not to it shows just where the urine is and if you are centered over the bladder or not....but then you also have to output and bladder tenderness to go by a point for good I&O's

[leslymill]

Okay..I do remember using one of those in my travel nursing days. I have used one of those in travel nursing,,,, You chec for residual urine with it? Yeah, you check after each void. I bet they do charge for it. If you chart it. I hope they wouldn't charge much though. Well not $300.

[dcnballmom, ASN, RN]

well back to writing orders without physician approval - this week rumor has it that my nursing home ADMINSTRATOR did that very thing too for a wound specialist consult - and the physician was not very happy to find out that the specialist had seen his patient without his approval, rumor also had it that the DON was "gonna have to fix that chart" - now whether that is true or not i have no clue, but it seems to me that there is a lot of people that want to overstep their bounds on this type of situation - needless to say, i wont even write an order for protective devices without physician approval, as my facility does not have a policy for that either - if i wanted to be a doctor i would have been smart and gone on to med school, but nursing is my career and has always been - i appreciate reading all the replies on this subject in general, glad to know i am not the only person in the world with this sort of dilemma

[AuntieRN]

I too have run into this with my charge nurses. I have had my license for a year and a couple weeks. If I need something like a laxative or tylenol or even a foley placed and it is not ordered, depending on who the doc is they tell me to just write itt. I will not just write anything. It is not in my scope and when it comes right down to it...if something happens it is my butt not theirs. No doctor is going to stand up in a court of law and say "ohhh I dont mind that nurses write orders for certain things....no its gonna be I did NOT order that. And its gonna be my license and I worked too hard for that.

I dont blame you for not writing orders regardless of who tells you its ok. We finally have a NP that covers for one of our doctors. Its been wonderful having her.

Good luck

[leslie :-D]

well back to writing orders without physician approval - this week rumor has it that my nursing home ADMINSTRATOR did that very thing too for a wound specialist consult - and the physician was not very happy to find out that the specialist had seen his patient without his approval, rumor also had it that the DON was "gonna have to fix that chart" -

*groan*

perhaps an anonymous call to the BON (or to the agcy who licenses your administrator) is in order?

or both?

yeah, many facilities do this.

and it really needs to stop.

if one wants change, do it the right way.

leslie

[K.L.A.]

I think the best thing you can do is get a list of standing orders. The hospital where I used to work had standing orders for each group of doctors that did rounds there. Another thing you could have done when you called the MD the first time with blood in the urine is to ask for irrigation if needed, then you already have the order if you need to use it. Doctors really get mad when the same nurse calls them more than 1 time per shift. They are a little ticky, you know.

Lots of luck

[hjwdancer]

well back to writing orders without physician approval - this week rumor has it that my nursing home ADMINSTRATOR did that very thing too for a wound specialist consult - and the physician was not very happy to find out that the specialist had seen his patient without his approval,

I'm a fairly new RN and I now work in a Medsurg setting. Please set me on the right path here but where I am at "we"- the nurses on the medsurg floor- could write for a consultation for a patients case as the pt's nurse. The consultation- for woundcare, nutrition or PT, etc- would review the pt info with us, pt, chart and/or doc if available and then leave a note in progress notes with recommendations for the physician... who would then choose to write or not write orders based on that info.

My basic question: Is this OK? After reading this thread, I am starting to become a little more paranoid. (As if I weren't paranoid enough as a new nurse...)

I would think it helps the physicians to have other professionals involved in helping with pt care. My rationale follows that I am not "ordering" treatment, medications, etc. My facility also has several admission flags that tell me if pt answers yes to certain questions then to immediately refer the case to the coresponding department (ex: nutrition for tube feedings, wound care for stage 3, etc). None of our docs has ever objected and it seems to be accepted as the norm.

Do other facilities also have these flags and methods?

Thanks!

H

[leslymill]

I'm a fairly new RN and I now work in a Medsurg setting. Please set me on the right path here but where I am at "we"- the nurses on the medsurg floor- could write for a consultation for a patients case as the pt's nurse. The consultation- for woundcare, nutrition or PT, etc- would review the pt info with us, pt, chart and/or doc if available and then leave a note in progress notes with recommendations for the physician... who would then choose to write or not write orders based on that info.

My basic question: Is this OK? After reading this thread, I am starting to become a little more paranoid. (As if I weren't paranoid enough as a new nurse...)

I would think it helps the physicians to have other professionals involved in helping with pt care. My rationale follows that I am not "ordering" treatment, medications, etc. My facility also has several admission flags that tell me if pt answers yes to certain questions then to immediately refer the case to the coresponding department (ex: nutrition for tube feedings, wound care for stage 3, etc). None of our docs has ever objected and it seems to be accepted as the norm.

Do other facilities also have these flags and methods?

Thanks!

H

It has to be incorporated into the facility's policy and procedures in order for them to bill for the NURSING consult. The consult and recommendations to the doctor are fine because you are not prescribing medical treatments: you are evaluating and addressing the pt.s needs FOR the physician. You are leaving the actual ordering to him.

[cmo421]

I'm a fairly new RN and I now work in a Medsurg setting. Please set me on the right path here but where I am at "we"- the nurses on the medsurg floor- could write for a consultation for a patients case as the pt's nurse. The consultation- for woundcare, nutrition or PT, etc- would review the pt info with us, pt, chart and/or doc if available and then leave a note in progress notes with recommendations for the physician... who would then choose to write or not write orders based on that info.

My basic question: Is this OK? After reading this thread, I am starting to become a little more paranoid. (As if I weren't paranoid enough as a new nurse...)

JACHO has encouraged certain types of NUSING ORDERS. These facilitate pt care. When the initial assessments asks questions regarding home safety,possible discharge needs,etc... then a social service consult can be ordered by nursing. If flags are raised at admission or during pt stay on nutrition,a consult can be ordered,they make recommendations and then the doc needs to order. PT evaluations are usually needed for ROM,transfer help,post op needs,etc,, this can also be iniciated by the nurse with follow up orders by the doc. It is all in documentation and the admission paperwork. Follow ur facilties policies and u will be fine.

The op and above are talking more about procedures,meds,etc,,, that sometimes are ordered by nursing when it is not covered under our licence or scope of practice.

[rn/writer, RN]

Take a look at the P&P at your facility. It should spell out what kinds of things would qualify as an NCO, nursing care order. At my hospital, I can order throat lozenges, a bilirubin level, or a change in meds from tablets to liquid form, among other things, without obtaining an MD order. As long as I stick to the "menu," I'm covered.