Maybe this is a situation where the difference between the UK and the US can be seen. (I'll admit that I'm assuming that you're US based)
'What if the doc is not present but you need an urgent order, such as pain or fever Rx or even a laxative or something for sleep or itching?'
On an acute site you get the on-call doc to prescribe it. There is a medical doc on call 24hr on site to deal with situations such as this. In nursing homes etc, most in my area are trying to bring in 'care bundles' otherwise they would call the patients GP on call who are obliged to either visit or refer on usually to A/E (ER). Neither the nurse nor doctor would have any protection as regards a verbal order in this area
Or what if the patient needs an ice pack or heating pad for comfort?
Why would I need Dr to prescribe that? That would be a nursing decision.
AS for a transfer from a nursing home to an ER, again that would be a nursing decision.
But I do feel I really have to comment on your 'hope for the best', how can that be considered best practice? If the doctor is being paid to give his/ her opinion make a decision why aren't they there?
AS for doctors secretaries I never have and never will do a doctor's documentation for them. Not my job. Nor do we have unit secretaries, the most we have is a clerk that would only work office hours and is there to stock/ order nursing stationery, answer phones, make out-patient appointments and file nursing documents.
It is drummed in to us from the day we start nursing school
that if it is not written down it is legal/ never happened. It is drummed in to us again by our unions that they can not and will not protect us, if we give a medication that was not prescribed.
I have witnessed a nurse lose their licence over this, yes they were possibly doing what was best for that patient, yes it was witnessed by another nurse, and yes the doc did come up to the ward the following day to prescribe the med, however in the mean time there had been an audit of the patient notes, this was picked up and as I said the nurse lost their job and licence.
This was a experienced nurse, no harm came to the patient, every one had the best intentions, but they did something illegal. That was the stand of the hospital and their union.
So for the convenience of one doctor, thousands of pounds in training cost lost and the a good nurse gone