Do you call the docs with EVERY order you need? I mean, if I called everytime I needed something, I would be on the phone alot. Do you guys? Or do you just write the order if you know the doc. Like if you suspect a UTI, write an order for a U/A. I have one this morning that is c/o penis pain, he had a catheter while in the hospital, was taken out about 3 weeks ago. So the initial pain of removal should be gone. I just called this doc yesterday and dread calling him AGAIN today. KWIM? When I worked in the hospital, I would write orders (only for minor things) if I knew the doc. Like for chloraseptic if the pt has a NG tube, or Stool for C-diff if on abx and with alot of diarrhea with that "smell". But with home health, I wasnt sure if I should, even though its the same docs I deal with. And yes, I know I dont have a license to practice medicine, thats not what Im trying to do. I just dont want to bother the docs and then them dread my calls.
May 20, '09
I do shift work home health, so hopefully some visit nurses will reply too. Their perspective may be different. My opinion is that you should NOT do this! If you need to call the MD, you need to. You are a nurse, the doctor is a doctor. Yes, there are sometimes shades of grey in home health, but I don't think this is one. Are there any standing order protocols for common symptoms?? I've had patients who had common recurring problems, and we had standing orders to follow. Like my one respiratory pt had standing orders we could follow if their resp symptoms flared up. It was nice not to have to call the MD every time.
By the way, you mentioned writing orders for simple things if you knew the MD when you worked in the hospital. Different areas of the USA are different in this regard from my personal experience. I won't mention places to avoid starting a fight (haha!). But where I was originally from you would have been at a minimum suspended, and at worst fired, for writing an order for a MD. Even if it was something simple like chloraseptic. The MD would have been ANGRY... Heads would have rolled! Big time! I am not exaggerating. But then I moved to another area of the USA, and I was shocked at the general leniency. The contrast was startling. Among many other things, I would see nurses write orders for simple things as you mention....
Last edit by ArwenEvenstar on May 20, '09
May 20, '09
I would only write an order for the doctor if it is regarded as something relatively inconsequential, I pretty much knew the doctor, and knew the doctor would be most likely to sign. If it is about something important, then call the doctor. The key to this is that you never implement or write the order on the MAR/TAR, until you have a signed order or a TO. That is what keeps you out of trouble.
Last edit by caliotter3 on May 21, '09
May 20, '09
everyone knows we have to have MD orders to anything but in some cases we have to act on instinct and knowledge, most docs are happy we are taking care of the patient in the community, others are still on the "i am the doctor horse",,,,i would not do anything invasive like labs without an order...once you know the patient you can incorporate standing orders into the 485, for example or every patient i have i with a foley i add in to obtain urine for u/a c&s at s/s of infection etc., that way you have the order and dont have to call the MD
May 20, '09
Thanks for all your replies. Its amazing how things are so different in other areas. At the hospital I worked at, they would get MAD if we called over trivial things. I was sometimes nervous to call a doc because they would say things like, "why are you calling me over this?!" I was like
. I guess thats the reason Im so nervous about calling them over some things. Adding things onto the POC for the 485 is a great idea.
May 21, '09
I would never do anything invasive without obtaining the order first. Having said that, I have submitted countless orders for signature over the years for frequency changes, minor changes in wound care like cleanse with NS instead of soap & H2O, etc, IF I was familiar with the doc. Never had a problem (knocking wood as I type, though)... Most docs would be pretty ticked if you called them with every little thing. Regarding wound care, the most common response I've had for request for wd care orders is "You know more about this than I do, just do what you think is best and I'll sign the order".
May 29, '09
I think it depends on the relationship you have with the patient and his physician. On my longterm cases I will write an order for a UA or simple wound treatments like skin tears and always document everything, alot of my docs allow notes to be faxed over or messages to be left with their office manager but I always call for med changes, labs draws and such
May 29, '09
If you are doing procedures, ordering tests, etc., without a provider's order, you are practicing beyond your scope of practice. When I have worked home health (granted many years ago) we had written protocols for what we could order. They were signed by the medical director and so were orders that we could initiate.
Nowadays, the nurses that work with me know to call me (I'm not scary) BEFORE they decide on a course of action.
May 29, '09
you are 100% correct saying that doing something without a MD order is practicing outside our scope, having said that.....in the world of home health, you work 99.9% of the time with verbal ordres, initiated by us, ( you assess your patient and find they have and open wound) you call the MD office to report, usually get someones voice mail) verbal order written, faxed or mailed to the MD and returns to the office anywhere around 14 days! i dont know any other way around it.
May 29, '09
lol... Im reading this post because I am a hospice nurse.. and quite frankly... I write a lot of orders.... but in my defence... the orders I write are from standing orders in which we have a ton of them.
However... if a doctor hasn't signed off on the standing orders... I am the first one to call them... and I dont really care if they get upset... and as they are ranting and raving at me whether it be in the wee hours of the morning or during their very busy day..... I always add... Dr... So and So.. we do have standing orders for hospice, can I send those to you again so we can reduce the number of calls? Generally that midmorning call and the gentle reminder to sign and fax us the standing orders.... does the trick....
If they get to particulary nasty.... I remind them that they are the physician and only they can make this call.... if they still yell and scream and hang up on me without the order given.... I call them back ( I am always pleasant and never lose my temper nor raise my voice... and my response when they answer the phone again is.. " so by your actions... your telling me you are refusing to treat our hospice pt?" That generally dampens their fire... they know me well enough to know.. that it WILL be charted. So far.. the docs that I know are very quick to give us what we need when we need it.. its the New "God Syndrome" out of Medical school that give us the most problems... but they catch on rather quickly.... We even have one doc... who is notorious crappy to nurses in the hospital... I mean.. down right hateful to where they cringe and even pay others to call him.... He hated me.... LOL.... I wern't scared of hi m....LOL
now that I am a hospice nurse... all of a sudden... I somehow grew a brain..LMAO
LOL.. but yeah... darlin.. call em... they put their pants on one leg at a time.. and if they didn't want the calls.. they shouldn't have become a Doctor... and I never apologize for calling them either. Its their job... if they dont like... they need to move on. HUGS.... and just to keep yourself safe and out of the legal drama's... call the doc... even if it is trivial.... if they tell you its trivial and you shouldn't be calling... them tell them to give you some standing orders for common ailments.... and you will happily leave them alone...LOL
May 30, '09
Thanks for all your kind words and advice. I truely appreciate it.
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