Is this practice illegal?

[LPNalltheway]

Is it legal for a nurse to go into patient's medication orders (in the computer) and modified them or add more medications under the doctor's name if verbally order by the doctor? I just do not feel comfortable doing this because I feel like I am ordering medications as a nurse...

Any thoughts?

[nursejami]

If you have an order from the MD, why would it be illegal...? You're just transcribing the order, just as if he had told you the order over the phone.

Now, whether it's against facility policy is another question entirely...

[klone, MSN, RN]

Yes, if you received an order from a doc, it wouldn't be illegal to transcribe said orders. However, it may be against your hospital policy. Where I work, we are not allowed to take verbal orders except in a code situation. All orders need to be written out by the provider. And where I worked last which had an EHR, the docs were required to input their own orders into the computer - nobody could do it for them. That was hospital policy, not law.

[LPNalltheway]

thanks to all! I just need to find out if is going against policy..

[klone, MSN, RN]

When you say you are going into the patient's record and "ordering them under the doctor's name" - are you actually logging into the system under the doctor's username? Or your own?

[PnutButterJelly]

This isn't illegal so long as it is being put in under your name and just putting in the doctor that ordered it. I work in an outpatient clinic and our doctors are only required to come in and see their patients once a month. If I need something I have to call the doctor and place verbal telephone orders into the system. If verbal orders were illegal I would never get anything accomplished and my patients would truly suffer because of it.

[klone, MSN, RN]

I work in an outpatient clinic and our doctors are only required to come in and see their patients once a month. If I need something I have to call the doctor and place verbal telephone orders into the system. If verbal orders were illegal I would never get anything accomplished and my patients would truly suffer because of it.

Does your clinic have midlevels who work there? What type of clinic is it that there isn't a ordering provider who's not there regularly?

[KelRN215, BSN, RN]

When you say you are going into the patient's record and "ordering them under the doctor's name" - are you actually logging into the system under the doctor's username? Or your own?

When I worked in the hospital, we as nurses could enter orders but there had to be a physician's (or NP's) name attached to it. There was an option to enter an order that required a co-sign (like a med) and something that did not (like a weekly central line dressing change which was considered standard of care). If I took a verbal order for a medication, I would enter it as ordered by John Smith, MD and say that it required a signature. The system would then alert John Smith, MD the next time he logged in that he needed to sign for this order that he gave. That's what I'm imagining the OP is talking about.

In home health, a significant percentage of the orders we get are verbal/via telephone. I enter the order into the computer, sign it as a verbal order and then it's sent to the MD for signature. There are no MDs lurking around to physically enter orders in the home health environment.

[PnutButterJelly]

Does your clinic have midlevels who work there? What type of clinic is it that there isn't a ordering provider who's not there regularly?

I work in outpatient dialysis. Most of our patients see our medical director, who is there once a week. However, the other patients see doctors from a large practice. They are legally only required to be there once a month. That practice is pretty notorious for doing as little as possible and only coming when required. They come in, see there patients, sign off all of their verbal orders, and aren't seen again for another month.

[cardiacfreak, ADN]

We use CPOE (computerized physician order entry). If we take a telephone order, we write it in the chart and then the doctor signs the order the next day. We are not suppose to take verbal orders, but we all know how a doctor will give that one last order as he is walking down the hall, {{sigh}}.

[LPNalltheway]

by klone "When you say you are going into the patient's record and "ordering them under the doctor's name" - are you actually logging into the system under the doctor's username? Or your own?"

Hi Klone, yes I am under my username not the doctor's..

[nurseprnRN, BSN, RN]

by klone "When you say you are going into the patient's record and "ordering them under the doctor's name" - are you actually logging into the system under the doctor's username? Or your own?"

Hi Klone, yes I am under my username not the doctor's..

Then if you are allowed to take a verbal prescription for patient care from a provider (NP, DO, MD, DC) you are doing just what you would do if paper charting still ruled. "(Date, time) Docusate 100mg qam and qhs, verbal order John Smith MD/Ann Jones MD. /signed/ LPNalltheway, LPN."

If you cannot take a verbal, then you can't do it on the computer either.