Facility Policy or State/Federal Requirements

[MrsBRN, BSN, RN]

I have a question regarding out patient clinic nursing care and the policies/regulations.

Situation: Orders are not placed for certain procedures pertaining to foley insertion/removal/void trials and wound care (simple and complex). The medical providers instead put documentation of what they want done in a progress note or in a comment box in the level of service section (where follow up information goes). I like to follow the rules and the facility has told me that documentation by provider is all that is needed. However when in nursing school (I have been a practicing nursing for about 4 years), I remember having it drilled into us that we needed an order for everything. I realize we focused mainly on acute care and inpatient hospital systems. This is why I am here asking for any information regarding this issue. I have poured over the Texas Board of Nursing, Nurse Practice Act (I practice in Texas), and spent hours going through CMS documentation. I have found nothing that fits the situation.

The question:

Is an order required to provide the above stated nursing care?

If so is that requirement federal/state regulated, or is it facility regulated?

What constitutes an order in the setting of an EMR?

Does a progress note work or other documentation work?

If it is a facility regulated issue I am aware I will need to take it up with them, I am actively seeking clarification from the facility at present.

Thank you for any and all guidance.

[Double-Helix, BSN, RN]

Yes, an order is required for some of the nursing care you described. Foley insertion requires an order. Removal usually does not. But there are other caveats. If the facility has protocols for voiding tests written by the physician that include foley insertion and removal, those many function as an order. If the progress notes are signed electronically or by hand, that could constitute an order. It may be that you need to tailor your CMS search to find out the mandatory components of a physician order and see if instructions written in a progress note actually qualify.

[MunoRN, RN]

An "order" just means the Physician has communicated aspects of the plan of care for a patient, such as inserting a foley, this can be communicated in a number of ways including in progress notes.

[klone, MSN, RN]

It's certainly not best practice, but as long as it has a date, time and the physician's signature (or name stamp in the case of electronic orders), it serves as an order, even if it's not done in the "official" order entry.

[morte, LPN, LVN]

but I do not look in progress notes for orders...

[MrsBRN, BSN, RN]

Thank you for the replies. I can see how a progress note, once signed can be used as an order, sadly most notes are not signed until well after the patient is gone, or end of the day. The LOS does not show name or a signature, so there is no way of proving who wrote what. The LOS really bothers me. I can get behind a progress note, but in past had a provider change the note to reflect another dx test then one originally, thankfully can see changes when the addend notes, but easier to see changes in orders.