Doctor charts later?

[nursefromcali]

Would be a licensed nurse can be in trouble if she/he drawing medications without doctors order yet? But it's the "doctor" administering the medication and he'll/she'll document it later on?

Is it a med error or malpractice habbit?

please comment or advice. thank you!

ps: doctor give the medication and document it "later on habbit"

[NICUmiiki, DNP, NP]

Where is this magical place where doctors pass meds? I want to be there.

I wouldn't go that far.... In my state nurses can manage propofol and precedex drips, but can't push it. In the ER, the docs would push those drugs to pop a shoulder in or something like that. The nurses also had to get their lidocaine for lacs and I&Ds.

[Horseshoe, BSN, RN]

Would be a licensed nurse can be in trouble if she/he drawing medications without doctors order yet? But it's the "doctor" administering the medication and he'll/she'll document it later on?

Is it a med error or malpractice habbit?

ps: doctor give the medication and document it "later on habbit"

Sorry for my wording. The doctor ordered it verbally. yes I'm from US here in californiai it's a ambulatory clinic.

I'm not getting why this is even a question.

Doctor says "get me 50 mcg of fentanyl IV now."

Nurse draws up 50 mcg of fentanyl, and hands the doctor the syringe, which he proceeds to administer to the patient IV (I agree it's rare to see a doc actually give the med, but that's the scenario, I believe).

Why is there any notion of malpractice, and why is the term "med error" being used? Did he ask for fentanyl 50 mcg IV, you drew up 100 mcg IV instead, he gave it, and now he says you made a med error?

And what do you mean by "habbit"?

[NICUmiiki, DNP, NP]

I think it's a case of a physician that constantly asks for meds to push and always puts in the formal orders later. I think the OP might be worried because the other physicians don't do it that way normally and she/he feels like something may be wrong with the situation... Maybe?

[ixchel]

No, the nurse shouldn't get in trouble unless it's against the facility's policies.

(I was being silly.)

[NICUmiiki, DNP, NP]

(I was being silly.)

What??? That's a thing?

[ixchel]

What??? That's a thing?

Indeed, it is.

[Rose_Queen, BSN, MSN, RN]

My only rule is that if I'm not giving it, I won't pull a narcotic or other controlled substance. We've had a few incidences in my OR where the anesthesia provider asks for a nurse to get Versed for them to give and then never documents it. Then it looks like the nurse might be diverting. If it's a code situation, yes, but that's an emergency and typically no narcotics are being pulled from the Pyxis as sedative drugs are part of the crash cart drug drawer.

[Conqueror+, BSN, RN]

I always think ahead to what will happen if the patient goes bad. Suddenly that order never gets written by the doc and he/she can't remember asking you to give them a thing. Now we have a situation where the only documentation is you pulling a med. Obviously places like the ED run differently but I would have to have a second nurse hearing the request to feel comfy. This is a bad habit for your doc to have.

[Wrench Party]

Are you talking about standing orders? We operate under a lot of those, for the sake of efficiency. If I had to wait for a doctor

to sign off on every med I ever gave at that very second, we'd never get anything accomplished

[Horseshoe, BSN, RN]

If the nurse writes the verbal order as soon as she hands off the med to the doc, and has him sign off on it before he leaves the immediate vicinity, I don't see what the problem is. But our docs were always good about signing their verbals.

[nursefromcali]

Thank you for the responses and informations. It's a big help. :)