Verbal Orders, Do you take them?

[nilepoc]

In my Hospital, a 300 bed teaching facility that has a level one trauma center and 24 hour coverage by all specialties, our surgical ICU is not allowed to take verbal orders. This practice stems from the nurses not being able to trust the residents to own thier verbal orders, and to prevent the doctors from allowing nurses to practice medicine without a license.

We have had many incidents in the past where residents have retracted verbal orders on rounds, when confronted by an attending. This is very bad, because our nurses come out looking like fools, and face the very real possibility of having and action filed against their license. Like I said above, to protect ourselves, we no longer take verbal orders. How do you prevent similar situations from occuring in your institution? Also, what is your policy regarding verbal orders.

The interesting thing, is that my most experienced nurses, know which residents they can trust and therefore continue to take verbal orders from some doctors. They know that they can get them written in the AM before rounds. Now, some of my inexperienced staff is trying to do the same and they are now getting hung once in a while, because they do not know who will own their orders in the AM.

Our staff is very vocal, and are getting upset that we cannot take verbal orders, and the rest of our institution can. We need to address this issue, but I am at somewhat of a loss, in how to aproach it. If verbal orders come back like they were two years ago, we are going to have many nurses practicing without a license.

So how would you rectify this perceived problem?

[mcl4]

The interesting thing, is that my most experienced nurses, know which residents they can trust and therefore continue to take verbal orders from some doctors. They know that they can get them written in the AM before rounds. Now, some of my inexperienced staff is trying to do the same and they are now getting hung once in a while, because they do not know who will own their orders in the AM.

Our staff is very vocal, and are getting upset that we cannot take verbal orders, and the rest of our institution can. We need to address this issue, but I am at somewhat of a loss, in how to aproach it. If verbal orders come back like they were two years ago, we are going to have many nurses practicing without a license.

So how would you rectify this perceived problem? [/b]

Is there a good reason why residents can not write orders?

With the shortage of staff, I see no reason why we should be doing the resident's job. I tend to think we enable physicians to be more dependent on us to do the simplist task as writing what they want done for their patients.

[nilepoc]

Well the reason that we are not allowed to take verbal orders, is because the orders are sometimes to general and leave too much flex in regards to what should be done. I.e. you can't write in an order book just bolus him until it works. While this might be the right path of care at the time. There is no excuse for a surgeon who is in house not to write for each bolus, or give a parameter to treat to , say a wedge.

Another thing is, I personnally am not comfortable taking a verbal order to start levophed when a physician has not even seen the patient. Unfortunately our attendings do not really see eye to eye and they regularly change the in modality of care of the week. so say you take a verbal order to start levo, and then on rounds the attending goes off, the resident sometimes will try and back out of assuming responsibility for an order, or make up an order that was not given. It is just better to have them at bedside when you hang the twentieth liter.

I have to quantify the severity of verbal orders we are talking about here. As you can see above, these are not tylenol orders. Its stuff like should we start the Thamfor that pH of 7.01? Well, if my new grad does not know that you should not give Tham on a renally comprimised patient, there is going to be trouble. As a charge nurse, I cannot be everywhere and do everything. So I am actually happy to see the no verbal orders rule in place. I could very easily see the resident backing out of responsibilty, for that order, based on the nurse not mentioning the renal comprimise. Granted they should have asked, but they could get out of that also. Maybe that renal comprimise happened after the Tham was started?

Anyway, it is kind of a circular problem, I just wanted to see waht other facilities were doing.

[nilepoc]

Oh and to me phone and verbal orders are the same thing.

[mcl4]

Another thing is, I personnally am not comfortable taking a verbal order to start levophed when a physician has not even seen the patient. Unfortunately our attendings do not really see eye to eye and they regularly change the in modality of care of the week. so say you take a verbal order to start levo, and then on rounds the attending goes off, the resident sometimes will try and back out of assuming responsibility for an order, or make up an order that was not given. It is just better to have them at bedside when you hang the twentieth liter.

I have to quantify the severity of verbal orders we are talking about here. As you can see above, these are not tylenol orders. Its stuff like should we start the Thamfor that pH of 7.01? Well, if my new grad does not know that you should not give Tham on a renally comprimised patient, there is going to be trouble. As a charge nurse, I cannot be everywhere and do everything. So I am actually happy to see the no verbal orders rule in place. I could very easily see the resident backing out of responsibilty, for that order, based on the nurse not mentioning the renal comprimise. Granted they should have asked, but they could get out of that also. Maybe that renal comprimise happened after the Tham was started?

Anyway, it is kind of a circular problem, I just wanted to see waht other facilities were doing. [/b]

I would be interested in a response to why certain nurses are going against the hospital policy and writing verbal orders given by residents? If I was in the position of being the charge nurse or supervisor, I would find this troubling. This isn't an area where some nurses may feel personally comfortable or not in taking verbal orders, but a specific policy that must be followed by staff.

Why put your job and licenese at risk doing the resident's job?

[Agnus]

I take phone orders. If I think the doc should see the patient in conjunction with a phone order I insist he come in. I try at all cost to avoid taking verbal orders when the doc is right there. I just ask him to write the order. If, for what ever reason, I must write it, then I get him to sign it on the spot. If he can give it then he can write it. If it's a situation where he can't write it that moment then he can at least sign it.

We take DNR orders over the phone but 2 RN's must witness the fact the doc gave it. When I was in school learning to take orders I had to have an RN witness it. If two RN's witnessed every phone order and the resident was made to write orders that he gave in person then they might get the hint. If he refuses don't carry it out.

[kaycee]

I take verbal orders from our ER docs all the time because if it's a patient in acute distress there sometimes isn't even a chart made yet. There is only one Doc that we make write the order or at least repeat it in front of other nurses because she frequently will say "I never said that".

She is a pain and hopefully will be retiring soon. We all know what she is like and are very careful because nothing is ever her fault.

[nurs4kids]

I'm at a teaching hospital and we take them all the time. We have had the occassional resident deny that he gave an order. Before he/she finished their rotation here, though, they dreaded ever telling that lie. It'd be alot easier to admit an error to the attending than it is to run to a floor 15-20 times a night to write orders. In the past, when we had a doc that denied an order, we'd start getting a RN to witness. We decided that was too much trouble, didn't really hurt him, but slowed us down a bit. Soooooo, now we just act like there's no other nurse available to witness the order, so he'll just have to come write it himself. When he gets to the floor, we try to all be sitting at the desk chatting..lol..j/k.

Seriously, we routinely take verbal and phone orders and rarely have problems.

[RNKitty]

I routinely take verbal and telephone orders and have never had a problem. Then again, I don't work with residents. In L&D, most of the orders are predictable and practically standard practice. I think it is horrible of doctors to not wish to take responsibility for their mistakes, and kudos to the nurses who call them to the carpet and make them REALLY sorry for messing with the nurses.

[mustangsheba]

I've always taken telephone and verbal orders. TO or VO is part of the signature. Fortunately, to date I've never had a problem with residents or staff not owning their orders. I do question orders frequently, however.

[Teshiee]

WHAT WE DID WAS HAVE ANOTHER NURSE ON THE LINE TO VERIFY THE ORDERS. I UNDERSTAND WHY NURSES ARENT ALLOWED WHY GET SET UP FROM DOCTORS WHO MAY SCREW YOU IN THE END. ESPECIALLY WHEN YOU WORK IN AN AREA THAT DOSAGES AND MEDS ARE CRUCIAL TO THE PATIENTS OUTCOME.

[Rustyhammer]

Working in LTC if we didn't call and get phone orders, we wouldn't get any orders at all!!

We do the assessment and place the call and with some docs pretty much tell them what we want.

In 15 years I've never had a T.O. come back and bite me.

I can't imagine working without the TO'S.

-Russell

[mcl4]

Originally posted by Rustyhammer

Working in LTC if we didn't call and get phone orders, we wouldn't get any orders at all!!

We do the assessment and place the call and with some docs pretty much tell them what we want.

In 15 years I've never had a T.O. come back and bite me.

I can't imagine working without the TO'S.

-Russell

Did your telephone orders eventually need to be signed. My previous long term care position, we wrote telephone orders on a triplicate form where one copy was mailed to the physician giving the order which needed to be signed and return within forty-eight hours.