I've been sent on my first traveling assignment to a small rural hospital. The people are very friendly, and the hospital is very small. I've been an RN for 7 years and have worked at 2 large hospitals, one of them being a Medical Center with cardiac cath lab, cancer center, etc. The other one was about the same. I need some help from the Allnurses community and would like some opinions as to a couple of issues. Example 1: I was being shown the admission process for a same day surgery patient. The RN training me has the patient sit down in their room, and hands him/her the consent form for the surgical procedure and the anesthesia consent. Neither are signed by the MD or MDA. The MDA hasn't seen the patient preoperatively and the MD had seen the patient a couple of weeks ago. There is not a current H & P on the chart (RN claims there isn't one needed because it's just a colonoscopy) RN starts to explain the surgical procedure including all the risks and complications and what might happen, etc. I was absolutely floored but just stood there and watched her do it. Same thing with the anesthesia consent. She explained to the patient all about general anesthesia. The patient signed both consents and the RN witnesses "the consent procedure" and signs off on both consents with neither the MD or MDA having signed them. I was always taught and specifically remember the teacher telling us in Nursing School that the RN "NEVER EVER" obtains an informed consent for a surgical procedure and that the duty of obtaining the consent and explaining the surgical procedure rests soley upon the doctor. I talked to the RN that did this in private and she told me she didn't see a problem with it and that they've just always done it that way... the doctor is really nice.. yadda yadda.... I reminded her that she's not a doctor and didn't they tell you in school not to do that ? She said yah.. but. Apparently all the RN's do this at this hospital. I'm uncomfortable explaining procedures to a surgical patient and to work around this am just going to hand the patient the consent ask him/her to read through it and sign it... I plan on adding next to the word "witness" the words "to signature only" which will signify that all I have done is witness that the patient signed this consent. I'll throw it in the chart and let this hospital worry about it. I don't want to raise a stink and be an ass. Just want to do my time here and get out. Example 2: The RN training me is showing me how to look at the pre-operative surgical and anesthesia order set. For the same colonoscopy, it was the standard.. admit patient.. start IV with LR @ 125... yadda yadda. All of a sudden she says " we need to do an accucheck" I'm looking at the surgical order WHICH WAS NOT SIGNED and I'm looking at the anesthesia orders WHICH AREN'T SIGNED as well, and I asked her "how do you know that" She says, she looked up in an H & P, which was 3 months old, that the patient has diabetes and JIM the CRNA (not his real name) says that whenever we see that the patient is diabetic, that we have to do an accucheck. I asked her if Jim was going to put that on his order and she said no.. we just always do it like that. She then takes a pen and writes onto the pre-surgical order "accucheck" I could not believe what I was seeing. I told this RN that I've never seen an RN just write in an order on a surgical pre-operative order sheet without the surgeons approval just based upon the fact that so and so said so. At this point, I told her flat out that I was not going to do an accucheck on this patient without a verbal order from the CRNA and that I was not going to sign that order sheet after she wrote accucheck on there prior to having obtained a legal verbal or written order. I also told her that I was uncomfortable providing patient care if this is the way the rest of the day was going to go. Here is the rub. The RN explains to me that this hospital is so small that it doesn't have to follow JCAHO or joint commision and that it follows the Rural Wisconsin Hospital Co-operative (or something like that) guidelines. She felt I was a big city RN and that "they do things differently" here in the countryside. I responded that she still needs to follow the basic principles of nursing and not provide care to a patient without being ordered to do so either with a verbal order or a signed written order and I didn't care what guidelines she wanted to recite. I was going to follow the basic principle of NURSING 101 that I was taught in college and I'm not going to so much put an ice pack on a patient without being told to do so either verbally or with an official post operative written and signed order and that I"m not risking my RN license that I worked very hard for. What do all of you think about this ? Am I just being a big city nurse, or are these RN's out in the country side way off base and putting themselves at risk by blindly following a set of archaic principles that might have worked 30 years ago ? It seems like everything here is just done by a feel good country way of doing things and I'm used to seeing a written order either on paper or on a computer before taking on a nursing care. I'm at a loss here and would like some opinions.