"No New Orders Received" ..... ? - page 5
When you notify the physician of something regarding your patient and receive no new orders, do you document that? I can just document: "Notified MD of infant's increased work of breathing. Will... Read More
Nov 25, '07Occupation: playing science Specialty: NICU ; Joined: Feb '05; Posts: 3,131; Likes: 1,042I've started being so much more careful about this recently. My primary at work is most likely terminal, but he's still a partial code (no meds, yes compressions) and his parents still believe he may pull through. The team has pretty much given up, though. So when I go in at night and there are no am labs written (which is almost every night) and I ask the resident or fellow "so, no labs on baby x tonight?" and they say no, I chart "Per MD Docling, no labs to be drawn at this time." Again due to the magic of computer charting, if something changes and they want a lab later, I can go in and erase it.
We also have a problem with some of the, um, less bright residents writing really stupid orders at 0645 and the fellow rarely has time to deal with it. Like the other morning the MD (actually the same one from my earlier post, in re the replogle secretions - god help us, she's back) wrote for an increased kcal formula on a baby who's been having explosive diarrhea and a bleeding diaper rash. Duh. So I call and point this out, and she just did. Not. Get. It. So I documented the conversation and didn't hang the new feed. There was still 4 hours of feeding in the bag (because I like to fill my bags right before change of shift to help out the next nurse) so by the time it ran out, rounds would have happened and they could deal with it then. Ahhhh.
Nov 26, '07Joined: Oct '07; Posts: 246; Likes: 101i am in awe of u nurses who can go to another dr. if u don't get needed orders,small town here,iv'e never heard of that ,except call our med director if your page,& calls to dr. don't get answered quckly enough. small town also has good ole boy system. i once torqed a dr. per phone whereas he reported me to my adon. he told me he would too. i calmly said I'm sorry u feel the need too! luckly, adon knew his attitude,but had to say she spoke to me about it i guess,she seem to be trying to appear neutral, never heard more on it, i only once needed to qoute dr in n.n.s requested stronger pain med,per pt. request."give her the xxxxx & i hope she chokes on it" i got the impression he may have thought he knew pt. was addictive personality,or worse.