Forgetting to write an order

tewdles, RN · Jan 5, 2010

Bottom line...if you are at a bedside and a doctor gives you a verbal order, it is his/her responsibility to write it...period. Too often docs have been under the misimpression that if they speak an order to a nurse they are off the hook for the documentation. This is exactly why many hospitals and facilities have adopted a strict "no verbal order" policy.

I am not surprised that you feel uncomfortable about this situation as in the absence of an order it would appear that you were functioning waaay outside of your scope of practice (assuming that you charted the administration of the "unordered" medications). My recommendation to you would be to actually verbally say to the doc..."please remember to include these meds in your orders and notes"...at the time of the verbal.

If this is an ongoing and persistent problem with one or more docs I would further recommend that you speak with your management team about the situation. All it would take would be one adverse event resulting in a legal review of the record and you will have a big problem on your hands. Keep in mind that the adverse event doesn't even have to occur on your shift or in your department...malpractice law staff are proficient at finding inconsistencies and errors in the medical record, and administration of a medication with no MD order would be easy to find. Good luck.

bigbub3000 · Jan 5, 2010

Was there a bad narc count? There should have been if it was a controlled drug.

In the future, just stick the chart in front of the doc and have him write it - now. Or, you can write it but stick the chart in his face and have him sign it - now.

Did you chart the med you gave or what? If nothing has happened by now, maybe no one noticed? I don't understand exactly what you're saying, I guess.

You need to still have the doctor write the order for that med, too. Nothing wrong with having him write it now and date it as a "late entry" for the correct date. If the patient is gone, just go to med records, have your work ID with you, ask for the patient's chart. They might not ask you why. People go there all the time for charts. Can you arrange to go with the doc so he can write the order? Or do you maybe want to check first to see if it was written. If policy at your place is for nurses to write the verbal and telephone orders, just write it, as I said before, and tell the doc he needs to sign it. Maybe you will have a blank order sheet with you in case there isn't one in the chart. You might also be able to have Med Rec send the chart to you at your work area.

If you feel uncomfortable with this, ask your Manager how you should handle it.

Or you can tell the doc the situation and ask him to write and sign the order.

If it was a non-controlled drug and you didn't already sign it, didn't anyone catch this, like a Pyxis monitor or anyone else?

Don't you hate having to clean up after doctors and everybody else?

tolerantgirl · Jan 5, 2010

Was there a bad narc count? There should have been if it was a controlled drug.
In the future, just stick the chart in front of the doc and have him write it - now. Or, you can write it but stick the chart in his face and have him sign it - now.
Did you chart the med you gave or what? If nothing has happened by now, maybe no one noticed? I don't understand exactly what you're saying, I guess.
You need to still have the doctor write the order for that med, too. Nothing wrong with having him write it now and date it as a "late entry" for the correct date. If the patient is gone, just go to med records, have your work ID with you, ask for the patient's chart. They might not ask you why. People go there all the time for charts. Can you arrange to go with the doc so he can write the order? Or do you maybe want to check first to see if it was written. If policy at your place is for nurses to write the verbal and telephone orders, just write it, as I said before, and tell the doc he needs to sign it. Maybe you will have a blank order sheet with you in case there isn't one in the chart. You might also be able to have Med Rec send the chart to you at your work area.
If you feel uncomfortable with this, ask your Manager how you should handle it.
Or you can tell the doc the situation and ask him to write and sign the order.
If it was a non-controlled drug and you didn't already sign it, didn't anyone catch this, like a Pyxis monitor or anyone else?
Don't you hate having to clean up after doctors and everybody else?

Yes, I hate cleaning up after everyone else. I feel like I take care of everyone else more than I take care of the patient and that makes me sad and disappointed. Another thing I hate, is that doctors are always in a hurry and if you don't do things fast enough, they become aggravated. If everyone would just slow down a little and think about what we are doing.

As far as the bad narc count goes, I don't think there is one. I took the medication out under the patient's name and then scanned that medication to that patient. So there is documentation that the patient received the med, but I don't know if the doctor wrote the order afterwards and of course this pops into my mind at 0330 A.M. I really am thinking about quitting nursing, I just can't believe I wasted all those years in school. I feel so defeated:(

MERRYWIDOW46 · Jan 6, 2010

We have a STRICTLY ENFORCED policy of NO VERBAL ORDERS unless a life or death situation. Pharmacy does not activate meds in pyxis without an order from the MD. GUESS WHAT, we have a totally computerized medical record. GUESS WHO has to enter the order?????????? YOU GOT IT the MD. NO ORDER, NO MED it's that simple. ONLY EXCEPTION is a CODE.

P_RN, ADN, RN · Jan 6, 2010

Keep a few order sheets on your clipboard and stick it in his face before he gets away.

If he's there and had 2 hands then no reason he can't do it.

Virgo_RN, BSN, RN · Jan 6, 2010

As far as the bad narc count goes, I don't think there is one. I took the medication out under the patient's name and then scanned that medication to that patient. So there is documentation that the patient received the med, but I don't know if the doctor wrote the order afterwards and of course this pops into my mind at 0330 A.M. I really am thinking about quitting nursing, I just can't believe I wasted all those years in school. I feel so defeated:(

I would wait and see. If a discrepancy was created, you will be asked about it, as the person who removed and administered the drug. If you are asked about it, simply state the basic facts (do not go into great detail, apologize, or act in any way as if you have done something wrong). The facts: It was a bedside procedure, the doctor gave a verbal order, you gave the meds as ordered. Period.

tewdles, RN · Jan 6, 2010

tolerantgirl...don't get too frustrated. We all go through times of doubt and distress in our nursing careers. What you have described has probably happened to more nurses than you could count and most of us (and our patients) survive it. The fact that the thought of this woke you in the night speaks to the fact that you must be a dedicated and thoughtful nurse...I would hate to lose you!

tolerantgirl · Jan 6, 2010

Thank you for all your words of wisdom. This has been a learning experience and I am going to make sure the doctors write their verbal orders if they are there. The idea about carrying an order on my clipboard is a great one and I plan to do that now. You all have made me feel so much better and that is why I come here- to vent and to receive great advice. Thank you.

bigbub3000 · Jan 9, 2010

Do not quit Nursing unless you are absolutely miserable or you win a big lotto.

If this is the worst that ever happens to you, you're doing ok.

Maybe you wrote the order on an order sheet that never made it to the chart or got put into the wrong chart, right? Or you heard the doctor say he'd write it/had written it but he must have written on the wrong chart. Who knows how these things happen? Right?