Lame, lamer, lamest.... - page 2
OK, you get a Telephone Order from a doc. You make sure the order's correct by reading it back to him and making sure it's complete, and then you write, "t.o. Dr. Schnook/T. Ired, RN right??... Read More
Oct 27, '02Joined: Dec '01; Posts: 3,165; Likes: 59Well, I just always thought charting in the nurse's notes "New orders for ____ rec'd from Dr. Schnook Re: patient problem" sorta covered it.... but who'm I to say?
I'll add the initials, but to me, it's just another redundancy that takes more time away from our patients.
Oct 27, '02Joined: Dec '01; Posts: 3,165; Likes: 59Originally posted by RadRN2
Wow... How'd you get the medical staff to agree to a system like that? Or did they not GET to agree?
Oct 27, '02Occupation: BSCN peds/nicu Joined: Jan '04; Posts: 0You can write a million times that an order was repeated and confirmed but unless you have a witness, a doc can still say he didn't give the order. In this situation we really have no sure fire plan to cover our butts!!!!!!!!!
Oct 28, '02Occupation: RN Joined: Aug '01; Posts: 2,276; Likes: 42We are pretty fortunate at our small hospital that our docs don't make a habit out of denying orders. Of course, if I even think there may be a problem with the doctor signing the order, I will get the second nurse on the phone to verify it. If we weren't allowed to take phone orders from our physicians our facility would probably close down. Being a rural facility with just basically family practice docs and no "house mouse" we would be up the creek without a paddle!! I can just imagine the admininstration to try and get this passed. It is still the "old boys school" with our docs, and they pretty much get whatever they want...Last edit by deespoohbear on Oct 28, '02
Oct 28, '02Occupation: RN, Elderly Mental health Joined: Jun '01; Posts: 3,115; Likes: 51Duckie, you covered my point exactly. Writing something down does not change the fact that it would be your word against the Dr's. The fact that you wrote down your version of what was said at the time, may support your version of events, but it is not proof. Getting a witness is good, but how many nurses' words does it take to balance out the word of a Dr?
Am I getting too cynical?
Oct 28, '02Occupation: RN Specialty: 7 year(s) of experience in ICU, nutrition ; Joined: Jan '02; Posts: 905; Likes: 281Gotta agree with Duckie and donmurray; it doesn't matter what you write, if the dr denies it, it's your word against his/hers.
I always document in my nurses notes that I called a dr, what the new order was, and when I carried out the new order.
Example: Dr. No called re: pt temp 101.5. New orders for Tylenol 1gm PO q 6h PRN fever > 101 and BC x 2 sites PRN fever >101.
Then I note when the Tylenol was given and when lab came to draw blood cultures.
This is in addition to what is written on the orders sheet.
Of course, like I said at the beginning, it's still your word against the doctor if he/she says that's not what was ordered.