is this legal?

[dcnballmom]

i was always taught that when you needed a physicians order for any type of treatment for a patient, you asked the physician first - before writing any type of order. in the facility where i work, there is a nurse that takes it on herself to write orders for all sorts of things - not medications, but treatments and orders for consults - the one that bothered me the most was when she wrote orders for a speech therapy screening on a patient when the doctor had specifically stated in the past that he did not want this done, but instead ordered thickened liquids for swallowing troubles this patient was having - the nurse that wrote the order - after finding out that the physician was adamant about not having the screening done - errored out the order on the physician order sheet, writing "wrong chart" on the order - in addition she also made a nurses note that the physician had given the order when in fact he had not - this again she errored out and again that it was the wrong patients chart - is this really a legal issue or am i making too big of a deal about this - I thought that as nurses we were to respect the physicians and work with them - not act as though we WERE the physicians

[suanna]

Falsifing a record-YIKES! she is playing with fire and likely to get burned. At my hospital swallow screens, speech therapy, thickened liquids are nursing orders. Is anyone else bothered by the fact that a nurse felt she had to be sneeky in ordering what was in the best intrest for the patient, and as far as I can tell, well within the scope of nursing practice:assessment, using support services to promote safety, evaluating potential swallowing risks- being a patient advocate. The doctor is out of line in telling the nurse he did not want what to my way of thinking was just good nursing care.

[meownsmile, BSN, RN]

There is a certain amount of nursing judgement that can play into this type situation. However, you have to know your doctor and need to have been in conversation with them regarding patient care. It could be this doctor had been the swallow study route with this patient before, so what would be the reason to go to the expense of redoing another swallow study and writing care that the doctor had already prescribed in the thickened liquids. I think she overstepped her bounds a bit writing an order like that and really went way out there by making documentation in the patients chart that the order was from the doctor.

[hollyvk, BSN]

i was always taught that when you needed a physicians order for any type of treatment for a patient, you asked the physician first - before writing any type of order. in the facility where i work, there is a nurse that takes it on herself to write orders for all sorts of things - not medications, but treatments and orders for consults - the one that bothered me the most was when she wrote orders for a speech therapy screening on a patient when the doctor had specifically stated in the past that he did not want this done, but instead ordered thickened liquids for swallowing troubles this patient was having - the nurse that wrote the order - after finding out that the physician was adamant about not having the screening done - errored out the order on the physician order sheet, writing "wrong chart" on the order - in addition she also made a nurses note that the physician had given the order when in fact he had not - this again she errored out and again that it was the wrong patients chart - is this really a legal issue or am i making too big of a deal about this - I thought that as nurses we were to respect the physicians and work with them - not act as though we WERE the physicians

There are at least 3 things wrong with what your coworker has done:

1. Falsifying a physician order--when she wrote in the chart that Dr. X ordered this.

2. Making a second fraudulent entry--when she covered herself by writing "wrong chart".

3. Interferring with the physician-patient relationship when she interjected her own views and attempted to implement that the patient needed ST.

What are the potential ramifications?

1. BON issues for the nurse for exceeding her authority and making fraudulent chart entries.

2. Medical board issues for her practicing medicine without a license.

3. State licensure issues for the facility for fraudulent chart entries.

If this is an ongoing issue with this nurse that your facility will not address, you always have the option of filing a complaint (you can do it anonymously) with the state health dept division that licenses your facility.

If the BON became involved, they'd want to know if other nurses were aware of what this nurse was doing and why none of those other nurses did anything about it--could be enough to get you a letter of admonition from the BON.

HollyVK, RN, BSN, JD

Never put your own license in jeopardy when a coworker does something stupid.

[dcnballmom, ASN, RN]

i believe that no one has actually considered turning this in because the facility that i work in - well it has that " termination at-will" clause in our contracts - myself included in that - - but the information i am getting here and other nurses opinions have been wonderful - maybe if i show this to her she will get the message - that its not a good thing to overstep your boundaries - if i happen to get a pink slip in my mailbox for even suggesting this to her - i will post it - wish me luck

[TrudyRN]

What she does is wrong but I would keep out of it unless she writes orders that the doc won't sign but then this nurse still carries them out anyway. She is responsible for her own actions and, believe me, one of these days, she will get caught but you needn't be the heavy.

Whoops, well I retract my advise, based on what Holly wrote above. I guess you'd better do what she advises. Better yet, consult an attorney in your own state and see what that person says.

[ZippyGBR, BSN, RN]

to be honest this whole thread sounds like a crock ...

i still find it amazing that theUSA sees it as perfectly normal to have to get permission from physicians to do Nursing care for patients or to have therapy input

is this A sad inditement of practice which ensures than Nurses remain as hand maidens ? or just yet another symptom of the financially messed up way in which the US healthcare system with it's obsession in billing the minutiae of care to ensure that the price of healthcare remains as high as possible...

[leslie :-D]

i personally knew of a ltc facility where the adon, nm and some nurses would write orders for prn tylenol, colace, ot/pt/slp consults, treatments. (the don knew about it).

one day there was an investigation by the state, r/t a minor injury a pt had sustained.

during the investigation, one thing led to another and it was discovered that a bunch of these nurses had been writing these orders.

the don, adon, nm and involved nurses were all charged by the bon.

the facility was in grave danger of losing their medicaid/medicare funding, and had to come up with a plan of correction within 30 days.

so even w/the md's signing these telephone orders, it was eventually found out because 1 nurse had written a t.o. r/t this pt who had been injured.

eventually everything comes out in the wash.

do it the right way, and always.

leslie

[XB9S, BSN, MSN, EdD, RN, APN]

Whilst not the most tactful of posts, I do have to admit that I understand where Zippy is coming from. My first thought at reading this post was I found it incredible that as registered practitioners there is a need to ask permission to request something that in the UK is considered a nursing issue as with inserting a foley catheter, inserting nasogastric tubes and many other interventions that I have read on this board.

With that in mind a recent thread highlighted that in the US your clinical examination and assessment skills differ greatly to UK nursing assessments.

The issue about falsifying documentation is inexcusible but in the UK this intervention is something that would be nurse initiated.

I suppose it just highlights the differences in nursing practice between the 2 countries again.

[traumaRUs, MSN, APRN]

ZippyGBR - I'm gathering that you are not practicing in the US. THis scenario is wrong on several levels for per our nursing rules. Different countries, different rules.

[ZippyGBR, BSN, RN]

i see you nicely avoided the issue i raised there traumasRus ...

i really do wonder why there is such an acceptance from those practising in the US of the need to get a Physician's permission to undertake task/ internvetions/ make referrals which are or should be firmly within the remit of the RN

[Silverdragon102, BSN]

i see you nicely avoided the issue i raised there traumasRus ...

i really do wonder why there is such an acceptance from those practising in the US of the need to get a Physician's permission to undertake task/ internvetions/ make referrals which are or should be firmly within the remit of the RN

What is done in one country is not always done in another country and we should respect that. Even in the US each state will have what is accepted as a RN and can be different in some areas. They also have the issues with insurance. Until we have chance to work in other countries and see how they work we should use this as learning and seeing what is different and hopefully be able to adapt some into our own practice. Just because it is right in one country does not make it right in another and we need to remember this

No reason why we can not put our thoughts to a thread but there are ways of doing it without disrespect, insensitive and insulting

[SharonH, RN]

There are several issues at play here. The most serious of course is the falsifying of medical records. That stands out to me as the issue which needs to be addressed most.

As for the speech therapy screen, in many institutions that does fall under nursing and does not require a physician order. I am speaking of a screen, not consult or eval and treat. If the physician was adamant that he didn't want the patient to have some therapy and the nurse acting as advocate ordered a screen in order to have evidence to present to him that the patient could benefit from ST, then that would have been perfectly legitimate. In fact, it might have even covered her in the event that the physician's plan of care was not beneficial and was in fact harmful, then a ST screen might have provided evidence to show that nursing did try to intervene on the behalf of the patient.

Which brings me to my next point. Someone stated that the nurse was interfering with the patient/doctor relationship. That is somewhat disturbing to me as we also have a relationship with the patient and we are not obligated to blindly go along with the doctor's plan of care especially if there is evidence that it is not benefitting the patient. Again, I am not sanctioning the nurses' actions in this case, there was a way to get things done and she clearly has crossed legal boundaries in this case by falsifying records.