Why Do Nurses Write: "no new orders received"?

mauxtav8r · Jul 12, 2009

I agree with those above who stated that "No new orders received" is merely the outcome of the call. Nothing more.

In the case where I disagree with the md's lack of action, I document "Nursing supervisor notified." Then, it's MY boss climbing the ladder for me. If she thinks we need more orders either she calls the original md back, or calls the medical director.

Sometimes it is all in how the original call is placed. If I'm not getting anywhere and the pt is having a big change in condition, usually the super is already in the room with me, so at the time of the return page from the md, I can truthfully say, after no new orders are received "My supervisor so and so is here, maybe she can give you her impressions of this pt's condition." Usually does the trick. She has much more clout with the md's.

RN1982 · Jul 12, 2009

It's more CYA than being cranky at the doc. I had a patient whose abdomen was firm and distended and was complaining of abdominal pain, had large amount of NG output, I notified the doc and I always document that they are notified and whether or not I received orders and if I received orders, what orders were ordered.

I don't do it to be a b----, I do it because I want my orifice covered when I am pulled into court.

Penguin67 · Jul 12, 2009

How does it cover you to say "repeated and verified"? The doc can still deny the whole thing.
I think VO's and TO's should absolutely never be taken except in a dire emergency. Whenever a VO or TO is taken, there should be a witness on the phone who co-signs immediately as having heard what the doctor ordered. That's not foolproof, either. Maybe there need to be cameras and microphones everywhere to record every last action and word.
The Dilantin IV story above - did the nurse tell the doctor what had infiltrated or only that an IV had infiltrated? Was the presence of gangrene told to the doctor? What was the final outcome for the nurse? for the doc? for the hospital?

1. Documenting "repeated and verified" shows that you did go the extra step and repeat the order back to the MD to verify that it was correct. Sure, anyone can deny anything, but doing this is a crucial step in error prevention that helps to catch errors before the final order is written. I have yet to see anyone deny a "r/v" documentation in court. That would most likely make the MD who denied it look pretty bad and help the plaintiff win their case.

2. I agree that verbal orders and phone orders should not be used unless absolutely necessary. That is why computerized orders are a big step toward error reduction, as the physician can write orders from any computer in the hospital or from home, and cut out the "middle man" nurse in the order writing process. But it still happens.

3. The story above, happened 18 or so years ago. I didn't have the patient, but here is what I remember...Yes, she told the MD what drug had infiltrated. He chose NOT to come to the floor to look at the site. The skin breakdown provcess happened over a few days, and the attending found it progressing rapidly form a burn the next morning, after being called by the nurse when the resident wouldn't come to the floor to see the patient. The hospital settled out of court, as the didn't like to have these things in the news. The case was complicated a bit, as one of the nurses who was with the primary nurse throughout the event died before the deposition was taken, thus complicating things a bit, as can be imagined. I am not sure what happened to the resident. I don't think he ever came back to our floor. The nurse was not held liable.

jnrsmommy · Jul 12, 2009

Wait...MD's actually read our notes and see when we state NNO?

Sitting here, reading a very interesting thread, eating my cereal after a bad night at work, and you just made my day. Although, now I have to clean up the milk

RN1982 · Jul 12, 2009

Personally, I hate verbal and telephone orders. Our med orders have a box we can check off if either are tele or verbal orders. We have a very large ICU so I will walk from my pod to the pod where the doc is (its not far) and hand them the chart and make them write their own order or I will write it but make them sign it as if they wrote it. Probably not the correct way.

Medic2RN, BSN, RN, EMT-P · Jul 12, 2009

Wait...MD's actually read our notes and see when we state NNO?
Tait

Actually, the doctor who wrote that blog had an issue with "No New Orders" being written on the patient's order sheet.

I document that phrase because it is part of our computer charting form that we have to fill out anytime we call or personally speak to a physician. I would never document it on the order sheet though....

texas_lvn · Jul 12, 2009

In the legal system however, if a nurse writes no new order received, it can be implied that the nurse thought new orders should have been received. It is best to write continue to monitor. This was from a conference I went to where a legal nurse consultant had spoken.

I went to a conference that said using "continue to monitor" meant that you actually had a pt on some sort of monitor. She suggested we use "continue to observe"

Baloney Amputation, BSN, LPN, RN · Jul 12, 2009

I guess maybe the "no new orders" statement is more of a qualifier that I did address the issue at hand. To me it's like saying I called the doctor, and "no new orders" was the gist of their response to indicate that the doctor did respond to my concern in some way, thereby covering both of our hides. IMO, writing "no new orders" is better than writing "OKAY! I'm not worried about it!" *click*

Batman24 · Jul 12, 2009

There is nothing wrong with stating no new orders received. It's not a dig at the doctor either. It shows the doctor was called on an issue and the doctor didn't order anything new at that time. Sometimes when I call I know nothing new will be ordered and I know nothing is needed but we do it just to appease the patient or family. We don't have to do this often but once in a blue moon we do as a CYA for all involved including the doc.

If we know something is indeed wrong it is then our job as our patient's advocate to go up the food chain to get them the care they need.

emmanewgrad · Jul 12, 2009

I like this "No new Orders Received" plan, I just graduated and passed NCLEX! So, I will make this a personal practice just to cover my little behind!!!!

NurseLoveJoy88, ASN, RN · Jul 12, 2009

I'll be a new grad in 2 weeks and I'm so grateful for this thread. Reading all these posts have given me alot of insight. Thanks nurses !!

vivacious1healer · Jul 12, 2009

If i have alerted an MD to abnormal lab results/vital signs or change in status and do not receive orders to re-evaluate, medicate or send to a test, then I will document the following:

Discussed patient's status/results with Dr._______. No new orders received. Will continue to monitor closely.

Now, if I truly believe this patient is 'circling the drain' and going down fast, then i will page the Rapid Response Team, who have been extremely helpful to determine the causes of the changes, and often take over with calling the doctors and explaining that something needs to be done ASAP, or they have decided to send the patient to ICU.

This usually works. Rarely do I ever have to page the Chief Resident, but will do if I feel the resident on shift is not listening or has an attitude problem that is endangering the patient's care.

Many of the new RNs have also done the copy/paste of the actual page (we have on line/text page system). The page is saved by the I.T. operator and can also be reviewed when there is a disagreement between the doctors and RNs of who was paged/when they were paged/what was stated in the page. The docs can't argue it.