doctor's orders

[liljacjac]

Being an LPN for 20+ years I have seen a lot of things. But until recently I have been seeing my coworker do something that I did not think a nurse could do. Or is it being an RN you are able to do this. My coworker writes orders ( new and old ) and have the doctor sign them. But he does not put verbal or telephone or his name in the order. He just writes it out. Has nursing changed and I did not get this memo. Just want to know what is the legal thing for me to do.

[Murse901, MSN, RN]

Neither an RN nor an LPN can legally do this. You must write T.O. or V.O., doctor's name / your name (read back) and sign the order.

Ex:

Tylenol 975mg PO x1 now for fever

T.O. Dr. Feel Good / M. Nursington, RN (read back) mysignature

JCAHO doesn't even like for us to write verbal orders. If the MD is there with the nurse, JCAHO wants the MD to write the order. The nurse is taking on a huge liability by doing this, especially if he is carrying out the order before it's signed. All it takes is one negative outcome and the MD is going to say, "Look, I didn't sign off on that, and that's not even my handwriting". The MD will not back you up, the facility will not back you up, and you will be hung out to dry in front of the Board of Nursing.

Always CYA.

Edit: The (read back) is not a legal requirement, but is a standard practice recommended by JCAHO. Everything else is legally required.