How do you know when to get an order?

allnurses Guide · Dec 23, 2015

When you need something.. that is when you call for the order.
I routinely will put in restraint orders without phoning the physician. I'll let them know later but I am not calling an ICU doctor to ask for a restraint. In the morning if my icu patient does not have any orders for labs or a chest x-ray, i will put the orders in for them. What I do is wrong though, you should always call and get an order when needed.
I have also had a physician tell me to put whatever orders I want under his name, to do what I needed so long as I don't kill the patient. In court that would never stand and I would be in major trouble.
Know what you are doing and the implications of such. I take verbal orders and document the conversation each and every time. There are some things I refuse to put the order in and require the physician to do it, such as orders for blood transfusions or heparin drips.

Just as an FYI, we just had a similar situation at a local hospital last year. An ICU nurse had historically "helped" the physician put orders in on patients (as, lets be honest, most do). The physician came in to discharge the patient, had to step out and asked the nurse to "get things set for discharge", the nurse put the orders in, physician came back and said "what are you doing you are out of line putting orders in under my name" reported her and she lost her job and had to go before the board.

Be careful it's your license! They wouldn't risk theirs for you.

Dobieb2009 · Dec 23, 2015

At our facility, we are by policy not allowed to take verbal orders; of emergency, pt must be seen and orders signed by md within 1/2 hr. Still, many of us break this rule with doctors we trust. But remember, that in the end, one and all will throw you under the bus! Just my experience.

ArmaniX, MSN, APRN · Dec 23, 2015

Just as an FYI, we just had a similar situation at a local hospital last year. An ICU nurse had historically "helped" the physician put orders in on patients (as, lets be honest, most do). The physician came in to discharge the patient, had to step out and asked the nurse to "get things set for discharge", the nurse put the orders in, physician came back and said "what are you doing you are out of line putting orders in under my name" reported her and she lost her job and had to go before the board.
Be careful it's your license! They wouldn't risk theirs for you.

At my facility we are allowed to put in verbal orders under the physician. All orders are electronic, it obviously shows the chain of who placed the order and under who but it is common practice. Maybe not the best practice.

allnurses Guide · Dec 23, 2015

At my facility we are allowed to put in verbal orders under the physician. All orders are electronic, it obviously shows the chain of who placed the order and under who but it is common practice. Maybe not the best practice.

I've had some nurses put in orders for me without talking to me first, some of them are not what I would have done, but I try to deal with that directly with the nurse and not get anyone in trouble.

ArtClassRN, ADN, RN · Dec 24, 2015

My next question is, do you trust verbal orders or do things need to phoned in or written before you'll give it? Meaning if things go south, what's to stop a physician from saying that she/he never called about the order?

If you want to make your life infinitely harder, the next time you get a verbal order, tell the MD, "What's to stop you from saying you never called about the order?"

Dranger · Dec 24, 2015

The only thing I will do in the ICU is at best x-ray (abdomen and chest) and restraints. There is a lot of evidence that daily labs isn't all that necessary unless there is a specific reason. We do A LOT of blood draws in the ICU and I have seen people get iatrogenic anemia pretty frequently, especially if they have other hematologic or GI issues.

A lot of nurses get into the habit of ordering CMP/BMPs or CBCs in the AM, but I am finding more doctors holding off on daily labs unless there is a clinical reason. (i.e. PT/INR because of liver failure and the patient has a paracentesis that day.)

Everything else? Just call. That's what they get the big bucks for by being on call. However be judicious, a lot of things can wait till the AM.

oldsockventriloquist · Dec 24, 2015

At our facility, we are by policy not allowed to take verbal orders; of emergency, pt must be seen and orders signed by md within 1/2 hr. Still, many of us break this rule with doctors we trust. But remember, that in the end, one and all will throw you under the bus! Just my experience.

I guess this is a good policy, but I'm wondering how often facilities institute policies like that one. Also, I think this a reasonable thread that is relevant to this forum section, since if something goes wrong with a verbal order or nurses giving certain meds at their on discretion, they can be liable (meaning they could lose their job and/or license). This is a concern not just for current nurses, but for people going into the field, since everyone should be exposed to the potential risks in this field and know how to handle them. I don't think this thread needs any more justification than that. For those that have posted about my username, I have changed it to one that does not include any professional titles that I do not have, so it should also be appropriate for this forum as well.

Editorial Team / Admin · Dec 24, 2015

At our facility, we are by policy not allowed to take verbal orders; of emergency, pt must be seen and orders signed by md within 1/2 hr. Still, many of us break this rule with doctors we trust. But remember, that in the end, one and all will throw you under the bus! Just my experience.

I think that may be a bit extreme. I take verbal orders frequently in the OR- no one in their right mind would make a surgeon scrub out to put in an order. I've also had to relay orders from the scrubbed in surgeon to a floor nurse. However, we are not to take verbal orders from a surgeon/physician who is in the facility and simply needs to log on to put in orders unless it is an emergency situation. All verbal (and telephone) orders go into the providers in basket to be signed off.

While the verbal orders aren't necessarily ideal, there's no way that a flat out denial is always in the patient's best interest.

oldsockventriloquist · Dec 24, 2015

I think that may be a bit extreme. I take verbal orders frequently in the OR- no one in their right mind would make a surgeon scrub out to put in an order. I've also had to relay orders from the scrubbed in surgeon to a floor nurse. However, we are not to take verbal orders from a surgeon/physician who is in the facility and simply needs to log on to put in orders unless it is an emergency situation. All verbal (and telephone) orders go into the providers in basket to be signed off.
While the verbal orders aren't necessarily ideal, there's no way that a flat out denial is always in the patient's best interest.

But, don't you have multiple witnesses in the OR. I guess in that circumstance it could be better, since many people can hear what the surgeon is saying. Although, it can be pretty loud in the OR.

ParalyticAgent · Dec 24, 2015

In the ER, we have a lot of gray area at my current job. We have protocol orders the physicians will flip if you do not use. A lot of gray area. If you do not put blood work orders in the computer, some will get annoyed. There is a lot of gray area. The protocols involve a lot of orders.

To be clear, orders placed per protocol are in no way a "gray area," so long as the orders are entered as "per protocol" and the protocol is followed. The medical staff has already "signed off" on those orders by making them protocols.

ArmaniX, MSN, APRN · Dec 24, 2015

The only thing I will do in the ICU is at best x-ray (abdomen and chest) and restraints. There is a lot of evidence that daily labs isn't all that necessary unless there is a specific reason. We do A LOT of blood draws in the ICU and I have seen people get iatrogenic anemia pretty frequently, especially if they have other hematologic or GI issues.
A lot of nurses get into the habit of ordering CMP/BMPs or CBCs in the AM, but I am finding more doctors holding off on daily labs unless there is a clinical reason. (i.e. PT/INR because of liver failure and the patient has a paracentesis that day.)
Everything else? Just call. That's what they get the big bucks for by being on call. However be judicious, a lot of things can wait till the AM.

I'm with you. I don't just go throwing in multiple orders and play doctor. Our doctors are habitual in daily labs. Usually when I see they have not ordered labs or xrays for the AM is that Sunday to Monday shift (aka new residents starting their week). So normally with those I will just do repeat labs and see what we have been checking daily. However, if the doc comes on the unit "did you want AM labs or not?" Is usually coming out of my mouth.

Saves me from the incoming resident throwing in all these STATS orders at 0620.

FurBabyMom, MSN, RN · Dec 24, 2015

When I worked the floor, I took verbal or telephone orders pretty frequently. We also had HAND WRITTEN order sheets. Good luck with that. You learn to decipher chicken scratch... We had protocols for things too - and in general I paged the physician as soon as possible when I had a need. If a patient has a critical lab result you have to (or status change, need for restraints when nothing was needed before, etc). If it was something that could wait I would wait until morning or if another coworker had to call the on call for that group/practice over something else. I put a patient on telemetry (K+ was super low) critical result had just been called from the lab, I'd paged about the result but in the meantime put the patient on telemetry - I anticipated that the attending would want them on tele (and that we'd give K+ and re-draw in several hours). That's about the craziest I ever did as a floor nurse.

I work in the OR now. Some orders are CPOE (*most* orders for patients are CPOE for many things - bed/placement orders, scheduled meds, most orders one would be needing as a floor/unit nurse). I can't really ask a surgeon to break scrub, put an order in for a specimen, a lab test, or blood products when the excrement is hitting the fan (or really in the normal pattern of a typical case). We take a lot of verbals and with out system they cosign the verbals/telephones that nurses enter. Some things are essentially "per protocol" - in that we ALWAYS do them (ex. foleys for cases expected to go >3 hours, if its estimated to be close to 3 hr, I DO ask).