Help Psych NP and feels like license is in jeopardy

[Euphrosyne7, MSN, RN]

Help!

Currently working in community setting part csu and part outpt. The csu is a mess, numerous med errors, pts admitted that are either not safe for unit or needing more care. Asking me to "give med orders" for pts who are not yet on the unit but in the "emergency services " area, before they are even evaled by a clinician, many times pts come in with all kinds of bottles of meds that the nurse cannot tell what pt is actually taking or not taking and expects me based on the pts word to do verbal orders for same overnights. I told them I feel my lic is in jeopardy there and habe told them i am not going to be able to work in that part of clinic effective immediately after this past weekend something happened , yet again, that i felt put pt in danger. They are telling me I need to give a notice.

Thoughts? Im meeting with ceo tomorrow who is a clinician and the agency is completely clinician run. No help from medical director, as for some reason she thinks it is ok, to give a verbal order for medications that have not been reconciliated before the patient is even seen by a clinician while in a holding area, that is voluntary and pt can simply leave at any time.

Thanks in advance and you can pm me if youd rather make private comments

[Jules A, MSN]

So I feel your pain but unfortunately if you are going to work on an inpatient unit this is how it goes. It is what physicians do and if we want this responsibility and high rate of pay it is what NPs do also. You are right to have reservations however because in my experience med recs done by ED nurses, love you folks but seriously?, are historically inaccurate.

So you can either quit, I would recommend giving appropriate notice because this really is not an uncommon expectation, or we can brainstorm ways to work around so your patients and your license remain safe. My favorites are:

-Order only the basics, prudent doses of sleep, HTN, DM, antipsychotic meds, prns to tide them through the night until they have their intake in the morning.

-Call and speak with the RN caring for the patient for any especially questionable items and document they clarified it for you.

-Check labs, prior to ordering known meds for example Li and VPA, verify tox screen and when in doubt order every w/d protocol known to man.

-If push comes to shove and its not too late you can always spend your time calling their pharmacy. I do this routinely in cases of complicated somatic regimens when patient isn't a good historian

-Again defer back to only the bare minimum. One missed dose of most medications isn't the end of the world and I'd rather err on the side of caution especially when the med rec looks suspect.

-In cases where the patient is a good historian and and RN calls me I have no problem ordering based on their report, as long as within safe and reasonable doses.

[Euphrosyne7, MSN, RN]

Hi Jules:

I think you are misunderstanding. I am working in a csu, it is a 9 bed unlocked unit. When I say emergency services, I do not mean emergency department. The emergency services in this clinic is a room where people go who are having psychiatric issues. They may then be sent home, sent to ed via a section or placed at our 9 bed inpt facility. I only work on the 9 bed facility which is in the same bldg as outpt for 3 hrs tues through thurs am. I do the rest of the day at outpt. Basically what they want me to do, is to give a verbal order for medications that a pt who has walked in off the street to ES says he/she is taking even before a clinician sees the pt. At times this medication can be suboxone, which incidentally I am not certified to prescribe. I can't check labs before anything as this is an acute maybe 3 day admission, to a facility that barely has a glucose monitor. They aren't even supposed to take anyone who may be withdrawing from substance or etoh. I have more than enough pts to keep me busy outpt for the three hours in the am, and there is no reason why they cannot place another prescriber in this area. Also what I am trying to explain is there is no med rec and if so, it is done by the clinician/therapist. So basically they wanted me to give the lpn medication orders on a pt who was not even seen by the clinician ( for all I know the pt could then report oh I just took 1000 pills) after I orderd and pt was given what supposedly is the prescribed medications. I feel like it is just a mess. I also work inpt in a real hospital psych unit and nothing like this is going on there!

[Jules A, MSN]

Got it although still not much different sans the labs. As with any self report I'd use my own judgement and only order the basics for overnight until they will be seen. If during the day I'd definitely call pharmacy for verification. If patient states they are on suboxone and you aren't able to order it under the medical directors license, or don't believe them to be truthful then don't order it. If this was the deal of the job when you were hired I'd try to figure workarounds to make it more safe in the meantime and if you want to quit then do the right thing and give notice.

[Ddhar]

Are they referred to the psych clinic after going through the ER? From what I am gathering they are not but they need refills..anyway have you told them to make the patient an appointment with the provider who normally prescribes their meds if they do not have one then im guessing they are not managed on meds and i agree with you something isnt right. You cant treat people for psychiatric issues you havent seen and getting basic labwork is just common sense considering how some psychotropic medications metabolized and the contraindications to some medical issues/medication to manage medical problems. I definately see why you feel this way good luck to you