Nurses can't just write their own orders...can they?

babynurselsa, RN · Aug 15, 2005

I have worked some places where nurses who know their docs very well take some platitudes. But this can be a risky practice. You will be up a creek if you overstep your boundries and your doc refuses to sign your order. THen you are practicing outside your scope and the BON will get you.

mattsmom81 · Aug 15, 2005

Sure...we can write them, but then what if the docs won't sign them??? Risky practice as mentioned. I ran into this a whole lot in rehab facilities as an agency nurse.

And I've also been told verbatim by some docs to just write their routine meds as orders, particularly in the middle of the night, and they'll sign them in the am.

Usually I will look for an excuse to call the doc about something else, and then run the medlist by them, if I have any misgivings..

Also depends on the setting and my comfort level with the docs.

elkpark · Aug 15, 2005

What you are describing is flat-out illegal (practicing medicine without a license, which is a crime), and when the day comes that a doc won't "cover" them for whatever they did, they will be in v. serious trouble.

Why take the chance? Is it to save the doctors the incovenience of a telephone call, or is it the nurses' egos? If it's to avoid "bothering" the docs, that's what they bloody well get paid so much for, and, if it's a power trip for the nurses, that's even scarier ...

You may want to make the hospital nursing administration and/or risk management people aware of this (anonymously, if you really can't deal). If the doo-doo hits the fan, the entire hospital could end up in trouble in addition to the few "bad apple" RNs, and that would really be a shame. (Of course, if administration knows about this and hasn't done anything to fix it, then whatever happened would serve them right ...)

Many years ago, I worked on a psych unit where the day shift charge nurse prided herself on knowing everything about everything (and yet, as is so often the case, exactly the opposite was true ...), and she would feel v. free to write "verbal orders" from the doc that the doc knew nothing about, because she was so confident that she knew best. I was the evening shift charge nurse, and came in one evening to find that she'd written an order for (and given) a full bottle of mag citrate to a tiny, frail, elderly gentleman, and was LAUGHING about it to us in shift report (that we would be busy with him that evening, ha ha ... :rolleyes: ) By dinner time, he was having projectile diarrhea; we'd no sooner get him and the bed cleaned up than he'd fill up the bed again; as this went on, he was getting so dehydrated and his electrolytes were getting so out of whack that he was having dramatic sensorium changes (standing up on the bed and dancing around in the diarrhea, getting aggressive with us when we were trying to clean him up, etc.) It was a horrible mess! His skin turgor, etc., was getting so bad, I was afraid we'd have to transfer him to the medical floor for stabilization. I called the doc a few times to update him, and we gave the poor little man huge honking doses of Lomotil or something to get him to stop. I also finally had a little talk with the doc over the 'phone, and pointed out that the chart said he had ordered this man a big dose of strong laxative at 3 PM, and now, a few hours later, he had ordered a huge dose of (whatever we gave him to stop him up), plus all these stat labs, etc., to deal with this crisis situation, and, looking at the chart, it looked like he (the doc) didn't know what the he77 he was doing ... And that (the day shift charge nurse) did this sort of thing all the time and he let her get away with it, but this time it really mattered (this little man could be in v. serious trouble) and she was putting HIS license on the line, too -- was that okay with him??? 'Cause it wouldn't be okay with me; if it were ME, I'd be having a little word of prayer with her about putting my name on orders I hadn't actually given her ... (He did put his foot down with her the next day, and told her in plain English he was done covering for her and she needed to stop.)

Taking verbal/telephone orders is one thing, but just writing down what you think the doc would probably want to do is entirely different. Frankly, I'm surprised that the docs do cover for these nurses you work with, and I hope they (the nurses) are fully aware that, if the day ever comes that something goes wrong, the docs definitely will not cover for them (and will be well within their rights to do so -- why should one of them take a fall for something the nurse did?) -- the nurses will be left to dangle in the breeze, and losing their licenses could be just the beginning ...

katwoman7755 · Aug 15, 2005

I know we don't have a license to practice medicine...but I do think you get to know your situation.....

I used to work inpatient rehab...we all new the rehab doc real well....we knew what we could and could't do with regards to orders...

For instance...small things....LOC, tylenol, pt used some sorta eye drop at home that wasn't carried over on the orders...these things we would not call for necessarily....and like say a UA C&S or stool for occult blood...if we saw something that warranted it, we'd write an order.

Now, with regards to everything else, we would call....but we would try to notice these things before end of office hours...although he never minded us calling even in the middle of the night b/c he knew it would be warranted.

Now, I notice you have posted on the travel nurse forum...I would think you would probably not get to know any of the MD's that well while on assignment...so I would do what was prudent....the other nurses will have to answer for them selves.

Kathryn

sockov, ADN, ASN, BSN, CNA, LVN · Aug 15, 2005

you could loose your lic. get sued, get fired, and loose your rep.

is that worth doing someone else's job?

not me.

laurakoko · Aug 15, 2005

HEY !!!!!!! If you don't read ANY other POST READ THIS

I also once had a doc who ALWAYS wrote, "resume home medications", as an order. So, like idiots, the nursing staff wrote the orders for the meds that the Rx bottles provided.......most of the time. A nurse before me wrote for Oxycontin 60 mg, 2 tabs everyday. ? 120 mg of oxy? I questioned it, and HARD. Called the pharm to see if that was even a correct dose, or did she mean the total dose was 60mg, and each tab was 30mg? Called the doc, he didn't have a clue... he said 120mg. OK. I clarified the order, as I had called him to make sure 120mg was CORRECT. He said yeah, she had been in bone CA pain for a long time. OK, if that's the case, seems ok..... Well, I gave it. It was written by the doc, AND I clarified it.

Her resp dropped down to 6/min, and her family was kissing her good bye. She was a DNR. She didn't die, but "woke up" days later..........

Well, the order, as by her Rx bottle was 30 mg a day. How that nurse got 120mg ???????????????????????

And the doc was an idiot. He had no clue, nor did care much.

BUT, the nurse who wrote the order, was an idiot as well.

We all went up for a small investigation.

Just leave the medication ordering up to the doctor. If he wants to not have a clue, let HIM/HER write for that much Oxycontin.

The doc did argue that he "never would have prescribed THAT much"

He didn't win cause I clarified the order, but the nurse who wrote it, could have also been held accountable, cause he said "she misinterpreted my original order".

Docs are powerful. Nurses WILL lose their licenses before they do.

And if, by nursing judgement, and obtained knowlegde you feel a dosing is incorrect, DON'T give it without question, and clarification.

I'm not saying not taking an verbal/telephone orders.......

but I think I could have done better by saying, hey doc, how about I give her some Morphine 2-4 mg now, and you come write what you want later....

Tweety, BSN, RN · Aug 15, 2005

I don't do it. We have a doc that is notoriously always telling us "just write for it, I'll sign it". He's pretty easy going nice guy and usually orders the same thing when we call like Phenergan is his drug of choice for nausea. A nurse wrote for it and the patient had a reaction and the doc smugly said "I never wrote for that medication". He was kind enough not to make a big deal out of it. He could have made a stink and this nurse could have lost her license.

Don't do it. As was said, it's practicing medicine without a license. Period.

live4today, RN · Aug 15, 2005

A sure fire remedy to this problem would be to have a list of things nurses can do, and a list of things nurses cannot do according to the BON in each state. When a doctor tells a nurse to "resume previous meds" or "write the order, I'll sign it later"..............hand the doc the paper with the list of things the BON states a nurse can or cannot do........no verbal confrontation necessary. Then, leave it at that. He writes it, or report him to your NM for not writing it. Seems plain and clear to me when done this way. Better than having your license revoked, and losing your job for doing something nurses are not legally allowed to do. :)

mattsmom81 · Aug 16, 2005

Personally I love standing orders and the docs who use them!! :)

Regarding writing the meds after a doc has told you to 'continue home meds'...of course ya'll are right about what can happen. I sure would never consider doing anything like this as an agency nurse in any case!

Sadly, facilities I've worked in frequently allow docs to write 'continue home meds' on their SO's...and browbeat the nurses if they don't keep the docs happy. Good old 'employment at will'...

Home Health Columnist / Guide · Aug 16, 2005

above are poor practices in this suit happy age. i'm not ready to put my license on the line.

it is because of errors in reconciling meds between hospital, home and other providers that jcaho came up with this 2005 hospital mandate to be implimented by 2006:

goal: accurately and completely reconcile medications across the continuum of care.

during 2005, for full implementation by january 2006, develop a process for obtaining and documenting a complete list of the patient's current medications upon the patient's admission to the organization and with the involvement of the patient. this process includes a comparison of the medications the organization provides to those on the list.
a complete list of the patient's medications is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization.

http://www.jcaho.org/accredited+organizations/patient+safety/05+npsg/05_npsg_hap.htm

january ought to be fun in homecare when i start requesting this list!

Mulan · Aug 16, 2005

I don't do it. We have a doc that is notoriously always telling us "just write for it, I'll sign it". He's pretty easy going nice guy and usually orders the same thing when we call like Phenergan is his drug of choice for nausea. A nurse wrote for it and the patient had a reaction and the doc smugly said "I never wrote for that medication". He was kind enough not to make a big deal out of it. He could have made a stink and this nurse could have lost her license.
Don't do it. As was said, it's practicing medicine without a license. Period.

Maybe he does that deliberately, hoping the nurses will write the orders, then if something does happen the nurse is at fault and not him.

Reminds me of the doctors that deliberately yell at the nurses when called so that the nurses won't call them and then if something happens to the patient and the doctor wasn't called it's the nurse's fault and not the doctor's.