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

[woody62, 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.

Some physicians and some facilities have standing orders which can be instituted by a nurse. But the physician must co-sign them at the earliest date. I once had a patient admitted as a direct admitt. His phyician was notified and said he would be in shortly. The patient was in septic shock and I placed two IV klines in him and also drew and sent blood for several different labs, as well as a KUB and chest film. When the physician arrived, he co-signed my orders. I did this only once and only because I knew the physician very well and knew he would back me up. I did violate my states NPA and never did it again. I have never re-written orders or falsified a patient record. This is where the nurse in question crossed the line. She should be reported to her state's Department of Professional Practice and her Board of nursing.

Woody:balloons:

[hollyvk, BSN]

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.

To our nursing colleages in the UK,

There are 2 very important factors controlling how nurses practice in the US:

1. Finances--over here the medical insurance entities that pay for the care a patient receives REQUIRE a valid medical order be documented before they will issue payment for the care and supplies.

So, no valid order for speech therapy = it won't be paid for. The care rendered by nurses at facilities is not billed as a separate charge; it's rolled into the daily fees charged by the facility based upon the level of care (with all the extra tests, procedure, and supply costs added to that). The ultimate result of this setup is that nursing has less power to influence how care is delivered as nursing does not directly control its portion of the moneys received for its efforts.

2. Litigation--over here people are lawsuit-happy. Any chance to reap a windfall when a professional makes an error is like holding a winning lottery ticket to many people in this country. As a result, there are many systems in place to reduce the risk of litigation, including requiring that nurses function both as scribes for medical orders and that nursing only deliver medical care for which there is a valid order.

Nurses over here are still free to institute nursing care orders as allowed at their facilities, but if it involves supplies, the facility will want a medical order documented so the supplies will be covered by insurance. Nursing autonomy is an issue that in part needs to be fought with medical insurance payers over here, unfortunately.

I hope this clears things up for you as to what goes on over on this side of the pond.

:smiletea2:

HollyVK, RN, BSN, JD

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

To our nursing colleages in the UK,

There are 2 very important factors controlling how nurses practice in the US:

1. Finances--over here the medical insurance entities that pay for the care a patient receives REQUIRE a valid medical order be documented before they will issue payment for the care and supplies.

So, no valid order for speech therapy = it won't be paid for. The care rendered by nurses at facilities is not billed as a separate charge; it's rolled into the daily fees charged by the facility based upon the level of care (with all the extra tests, procedure, and supply costs added to that). The ultimate result of this setup is that nursing has less power to influence how care is delivered as nursing does not directly control its portion of the moneys received for its efforts.

2. Litigation--over here people are lawsuit-happy. Any chance to reap a windfall when a professional makes an error is like holding a winning lottery ticket to many people in this country. As a result, there are many systems in place to reduce the risk of litigation, including requiring that nurses function both as scribes for medical orders and that nursing only deliver medical care for which there is a valid order.

Nurses over here are still free to institute nursing care orders as allowed at their facilities, but if it involves supplies, the facility will want a medical order documented so the supplies will be covered by insurance. Nursing autonomy is an issue that in part needs to be fought with medical insurance payers over here, unfortunately.

I hope this clears things up for you as to what goes on over on this side of the pond.

:smiletea2:

HollyVK, RN, BSN, JD

Not wanting to get too off topic I suppose that there are benefits and problems with both systems affecting the nursing care we deliver. Within my post I did not intend to suggest that either system was better than the other merely to highlight that there are big differences between the two. Apologies if any offense caused