adding to doctors orders... legal or not?

Editorial Team / Admin · Sep 29, 2005

Let me put this in a scenario... I work in a nursing home. We receive Junes physician order sheets (printed out from the pharmacy) on May 16th. They are checked and any changes are made. Doc makes rounds on the 29th and signs his orders. Orders are then placed on charts. On June 2, I receive a new order for Lasix. I write it on a telephone order sheet, place order on current MAR, fax order to pharmacy, make entry in nurses notes, administer the medication... am I finished? No, not according to my DON. She thinks I should also go back and put it on the orders which the doctor signed on May 29th (with my signature and the current date). I have been taught that you do not ever add to something the doctor has already signed, but she says it is ok, if I sign my name and date it. I am very uncomfortable with doing this, but have been told I will be written up if I do not put new orders on those order sheets. What is the right thing to do? If I am correct, and I am not legally supposed to write a new order on something that the doc has signed, can anyone give me reference to something legal (nurses board, etc) that I can show as proof of my case? Or am I just wrong? Help! Thanks!!
BTW, if it makes a difference, I am in GA.

Hello, nursepeachie,

As far as I know, it is NOT all right in any state to add orders after the healthcare provider (physician or NP) signs them. Now, you can write new orders and have them sign them, but, never go back and squeeze in an order on the same day where the healthcare provider has already signed the order. This is illegal.

suzanne4, RN · Sep 29, 2005

You can never go back and add anything to your physician's order that her or she has already signed.

It must be written as a new order. Sorry, but your DON is incorrect on this one.

grannynurse FNP student · Sep 29, 2005

Let me put this in a scenario... I work in a nursing home. We receive Junes physician order sheets (printed out from the pharmacy) on May 16th. They are checked and any changes are made. Doc makes rounds on the 29th and signs his orders. Orders are then placed on charts. On June 2, I receive a new order for Lasix. I write it on a telephone order sheet, place order on current MAR, fax order to pharmacy, make entry in nurses notes, administer the medication... am I finished? No, not according to my DON. She thinks I should also go back and put it on the orders which the doctor signed on May 29th (with my signature and the current date). I have been taught that you do not ever add to something the doctor has already signed, but she says it is ok, if I sign my name and date it. I am very uncomfortable with doing this, but have been told I will be written up if I do not put new orders on those order sheets. What is the right thing to do? If I am correct, and I am not legally supposed to write a new order on something that the doc has signed, can anyone give me reference to something legal (nurses board, etc) that I can show as proof of my case? Or am I just wrong? Help! Thanks!!
BTW, if it makes a difference, I am in GA.

No, no, no. You write a new order, such as you did. I know of no state that allows what your DON is suggesting.

Grannynurse :balloons:

nursepeachie · Sep 29, 2005

You can never go back and add anything to your physician's order that her or she has already signed.
It must be written as a new order. Sorry, but your DON is incorrect on this one.

(Like I said, we do write it as a new order on the telephone order sheets.)

So, even if I add the current date which I received the new order on, it is not ok to add it to the monthly order sheets which have already been signed. That is exactly what I thought. But, like I said, I will be written up and disciplined if I dont do this. Where can I find something to back me up? I desperately need this, and cant find it anywhere! Thanks for the help!!!! :)

elkpark · Sep 29, 2005

I think your best bet is to contact your state BON and get an opinion from _them_ -- in my state, at least, the Board is v. good about hearing and giving opinions on anonymous, "hypothetical" questions (not, "Hi, I'm Jane Brown at XYZ LTC facility and this is what we're doing, what do you think?" but "Suppose someone somewhere were doing (what your DON wants), what would the Board's position be on whether that were legal and within the scope of nursing practice?")

It can't hurt to call and ask whether they are willing to answer your question, and their opinion is the only one that really matters, anyway. If they support your position (which I imagine they would; I've never heard of anyone approving of what your DON wants you to do), then you have a "hard" reference for your DON.

Jolie, BSN · Sep 30, 2005

Wow! An attorney would have a field day with this practice! Adding an order after the sheet is dated and signed by the provider is clearly improper, especially since it is being added days later.

That your DON would discipline you for refusing to participate in this improper process makes me very leery of her. Is she lazy, known for cutting corners, trying to cover up something? I would definitely take this to the BON and/or an attorney.

sjb2005 · Sep 30, 2005

A similar thing happened to me within this past year. Since I do the chart checks and audits, I ran across this many times. Nurses were lining out the physician's hand writing and correcting the orders. Since I felt this was inappropriate and risky, I brought the matter to the DON and the assistant manager 3 different times. Since I got virtually no input or resolution, I thought I was over reacting. I called my BON. They set me straight. They recommended that I demand an emergency meeting with the department heads and the medical director to get this fixed. They also stated that too many nurses sit infront of the board and loose their license for things like this. Write and order clarification and put it in the correct order per the date. That's what I have always practiced. I left that position because of the backlash for doing the right thing.

CoffeeRTC, BSN, RN · Sep 30, 2005

What is her reasoning on adding it to the monthy reorders? It will show up on next months reorders. Totally unnecessary. If the order was received after they were sighned, what she is telling you to do is add it on like it was ordered on that date? What happens if you get an order in the middle of the month, does she want you to add that also? Stupid if you ask me.

gerinurse10 · Oct 1, 2005

I had a state reviewer tell me to add new orders to existing MD orders (assisted living). Of course I asked if this was the right thing to do and he said yes. It still freaks me out to write on an existing order. We have service plans similar to homecare that we get an MD to sign every 120 days to verify meds etc. This is the form he wants us to write on. We also write up VO between the time the MD signs our initial service plan. I still don't get the rationale behind writing on the order. :rolleyes:

barefootlady, ADN, RN · Oct 1, 2005

There are very few "nevers" in nursing or life, but I was taught you "never" add anything to a physicians order. It is either a new order or a clarafication of an existing order. I do not relish you the job of reporting this to the board but I would make that call for clarafication of what a nurse is required to do since your DON is not informed on lssues that cause nurses to lose their license. Good luck and start looking for a safer place to work.

Hellllllo Nurse, BSN, RN · Oct 1, 2005

I don't know where this DON got her license, out of a Cracker Jack box, maybe?

Sorry you are being put between a rock and a hard place.

That's one things about nursing that really bites.