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?

[MrChicagoRN, RN]

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

Its not illegal, but we don't know if taking verbal orders goes against your policies or not. We don't work there.

Or, do you mean phone orders?

[LadyFree28, BSN, LPN, RN]

Its not illegal, but we don't know if taking verbal orders goes against your policies or not. We don't work there.

Or, do you mean phone orders?

This.

Best practice is to find out what is your facility's policy, and go from there.

[LPNalltheway]

they are all verbal... just some of the doctors are a little lazy to modified or added medicines by themselves

[applewhitern, BSN, RN]

We do it all the time. We simply place the order under our own name/password, then mark "verbal or phone order." How do you think we functioned before? We are completely paperless, so we do not write the order for the doctor to sign; the doc can sign it on the computer. We do not have doctors "lurking around" our hospital; even our hospitalists don't stay in the building. Just be sure you get the order right.

[LPNalltheway]

We do it all the time. We simply place the order under our own name/password, then mark "verbal or phone order." How do you think we functioned before? We are completely paperless, so we do not write the order for the doctor to sign; the doc can sign it on the computer. We do not have doctors "lurking around" our hospital; even our hospitalists don't stay in the building. Just be sure you get the order right.

I am a new nurse, so I do not know "how we functioned before"... thanks for the feedback

[toomuchbaloney]

they are all verbal... just some of the doctors are a little lazy to modified or added medicines by themselves

If the well established policy is for the providers to enter the orders themselves they should be entering the orders themselves.

DO NOT FACILITATE THEIR LAZINESS

[anon456, BSN, RN]

We are allowed to take telephone orders only if the MD is calling from home or outside facility. This is very rare on my unit. Usually it's the case of a surgeon who "owns" the case and no one else has been assigned. I follow the repeat back/verify to the doctor and then the order has to be reviewed and approved by pharmacy before the medication is available. It's one more safety check to make sure the wrong dose is not given for the child's weight/age. The MD then has to approve it within a certain period of time.

[Here.I.Stand, BSN, RN]

We also use CPOE; however on occasion we'll get a verbal order when the MD is very busy (say, in the middle of admitting someone w/ a GSW to the face) and not able to put my order in right at that moment. So I'll repeat the order back to him/her, go to the computer, and put in the order. Type is "Verbal order with readback," Provider is "Busy Resident, MD" and Entered By is "Here I Stand, RN."

Now if I put it as a "Standard" order, entered by "Busy Resident, MD" then that would be false documentation. What you describe is the process for entering a verbal order.