getting order changed

SDALPN · Feb 21, 2014

Hi!
I am new to PDN so I just have a question about getting an order route changed :-) My client has an OTC cold med that is ordered to be dissolved in her G-tube but she wants to let it dissolve in her mouth as she has apparently done in the past. The med is ordered to be taken this way on the box. (She is able to eat/drink so taking it PO is not an issue with swallowing). I wanted to call the Dr. to get the route changed, but how do they give you that order in writing?? There is no fax machine in the home. If the order is verbal over the phone, how long is that good for? And how do you document changes to orders? I have her POC with her meds listed on it, but that isn't re-typed up every time something is changed is it?? It looks like this is written up every two months or so and then signed by the Dr.....how does this all work with PDN? Thank you!!!

Wow. I suggest you talk with your supervisor about this. You haven't had enough training for the job, which is your agencies fault. Its important that your supervisor be aware that you don't know this. An order clarification is needed and your office has a fax machine the physician can fax to. Your agency should have forms to write a verbal order on in the home. POC isn't changed every time, that would be ridiculous. It will get updated in the next certification period. You really should know this before working in the home. Your agency should be training you on these things before you go in the home. Very scary!

clearblue3 · Feb 21, 2014

Well, thank you...I think. I don't work for an agency. Yes, lack of training can be very scary...however, you make it sound like I am risking my patient's life. I have paperwork questions. I have gone through everything on the POC and have called the RN at the MDs office to clarify many things on this POC and to have things re-written so things are very clear. I am doing things very by the book, questioning everything. Just because I don't know how the forms work does not mean that this is a "scary situation." I purposely took a client that is not vent-dependent and the skills required for the job are very new grad appropriate. Before recently moving to my state, this patient only qualified for CNA type caregivers in her home state. I understand the advice on here to not take certain clients as a new grad. I am not willing to risk anyone's life just so that I can have a job. I am simply asking how a change in an order would work for an OTC PRN medication for a cold. I was actually the one that caught that this med should not be given as ordered...by G-tube and discussed this with the patient's pharmacy. I DID NOT give the med in a different route than it was ordered even though that is how the patient has always done it. There has to be other PDN cases that do not have fax machines available. The RN said she would mail the clarifications out after talking to the MD. Maybe a dumb question, but a verbal order is usually good for x amount of hours in the hospital and then it has to be signed. I was simply wondering if this is how it works in PDN as well. Not every patient is going to have a fax machine or an agency so if you have to wait for an change in order to be mailed out, how long can you follow verbal orders? I received training on this case, but can you tell me that you will never have a question after training? I don't care if I a person has worked acute care their whole career, care in the home is different and questions will still arise. I don't work for an agency, like many other PDNs in my area. We have to rely on each other and other nurses to bounce things off of. Rather than just doing what the patient wants or how "it has always been done," I am questioning things, calling the MD and pharmacist to clarify things etc. Making sure everything is done by the book. Personally I am proud of myself for doing that.

Thank you for your concern, but please also know that the way you come across is harsh and not at all supportive. I am new to this and subsequently have questions. If you would like to answer them, it would be greatly appreciated. If you just want to tell me how inadequate I am because I have questions, then please refrain from responding. I do not mind honest advice, but said advice can be given in a kinder way IMHO.

caliotter3 · Feb 21, 2014

You need to discuss this with your supervisor.

clearblue3 · Feb 21, 2014

I don't have one. I don't work for an agency. I am hired by the client and bill medicaid directly. The RN at the MD office said she would get me a verbal order for the route change today. I am just trying to contact Medicaid right now so that I can find out the policy on how long the verbal order would be good for. Thanks!

clearblue3 · Feb 21, 2014

ok so don't eat me alive for this, but if you were an RN on this case and had questions but no agency, who would you direct them to? For policy questions, forms etc.?

SDALPN · Feb 21, 2014

Ok, that makes a little more sense. It appeared as if an agency did some really poor training at first. Most of us work for agencies doing PDN. Are you an LPN or RN? That will make a difference if you can fill out the POC. An RN is supposed to complete the 485 and then the Dr signs it, making it an order. If you don't have a fax machine, I'm not sure how you would go about getting a verbal order signed and sent back to you. Maybe by mail?? Calling whoever insures them may help you get the info you need.

JustBeachyNurse, LPN · Feb 21, 2014

Does Medicaid issue a handbook for billing & documentation requirements?

caliotter3 · Feb 21, 2014

No fax, do everything by snail mail. Agencies do it that way if necessary. Just make sure you keep a copy.

brillohead, ADN, RN · Feb 22, 2014

My agency has a triplicate form for telephone orders. You fill it out based on what the orders are, keep the bottom copy in the home chart, and send it in to the agency. The agency then is responsible to get it signed by the provider. When it's signed, the agency returns one copy to the home, and the original unsigned "bottom copy" is then discarded and the now-signed version is placed in the chart.

If you don't have an agency, I would do the same type of thing -- write out the orders as given, including who gave the orders, when (date/time), the fact that they were verbal/phone orders, and the date that the hard copy was sent to the doc's office for signing. Keep one copy in the house and mail the other to the doctor for a signature.

If your doc's office is willing, you could also write it up as you receive the order and keep that in the chart, and indicate that the doctor's office is snail-mailing you a hard copy with the doctor's signature.

I know that some cases require an ORIGINAL signature from the provider, not a fax or carbon copy. Not sure if that's for Medicaid or private insurance, I just know that there are some cases that require it, so you may want to check on those requirements in your situation.

txredheadnurse, BSN, RN · Feb 22, 2014

In addition to what the previous posters wrote I would suggest since you are basically an independent contractor that you either get a bound journal or make a time & date stamped electronic entry of every transaction you conduct in regards to orders just in case things get lost or someone tries to deny they gave or rescinded an order. This could also serve a secondary purpose of helping decide in the future how much time you would need to handle similiar cases so you can bill accordingly...if the payor source allows billing for obtaining orders etc.

KATRN78 · Feb 23, 2014

Is the patient aaox3?

If so, and they choose to take the medication orally, themselves.

"Patient reported to nurse that he/she self administered X medication orally at 9pm."