"Taking a verbal" = writing your own orders?!

[delphine22]

So I'm orienting in an MICU. Having a nice conversation with a nurse, well regarded on the unit (just won an award), had worked there for decades, and is not my preceptor. She mentions that one of the problems I'm going to have coming to the unit, that many PCU nurses have, is I'm not used to the level of critical thinking doctors expect from me.

"For example," she says, "if I'm worried about my patient, I'll just go ahead an order a gas! If I think there's something up with his abdomen, I'll have a KUB done. This way I'm prepared when I call the doctor!"

I was horrified. For years I had been told the story of an ER nurse in my hospital who wrote a phantom order just once (not for a med, for a blood test I believe) and was fired on the spot. I can't even get skin care creams without an order. She said "Oh, we take verbals all the time."

To me, that's different. If a doctor rounds, and says, "OK, we'll recheck BMP and mag in 4 hours," I smile sweetly and say, "Will you be putting those orders in yourself, sir, or do you need me to write them for you?" We are 100% computerized order entry, and written orders are frowned upon unless they truly are from the telephone, but I don't mind if they won't be near a computer and it gets things done faster.

But I'd never dream of ordering a test without speaking to a doctor first! Luckily this will never be a problem for me; we have remote-monitored eICU at night, when I will be working, and there is always an intensivist available at the push of a button. And it's usually not a problem for her, as the usual daytime intensivist writes his own orders on the BMW in the middle of interdisciplinary rounds. But some weeks an off site intensivist is in charge.

I know I'm not crazy when I say it's wrong. But this is a judgement free zone: are there places where this is considered OK?

[grandpaj]

Do you have protocols in place for ordering such tests without specific physician approval? Where I work, RT can order abgs if needed as part of the protocol if the physician has ordered an RT assess and treat. EKGs can always be done stat without an order. Other tests are per protocol, conditional/verbal orders, etc.

The hospital could discipline you if the physician gets upset about the situation. I personally never order anything without an order or a protocol in place to do so.

[VANurse2010]

I only put in orders that are covered under protocol (fortunately in my unit, ABGs are covered - basically whenever RT or the RN feels one is necessary). I have given pushes of fentanyl when a patient was seriously agitated (like RASS +4) and about to self-extubate - but that was an emergency and the doctors gave me the orders after the fact. I have also put in chest xrays when a patient was having acute respiratory distress (without calling first). I wouldn't order imaging or labs outside an emergency based only on my nursing assessment (e.g. I think that nurse is out of line ordering a KUB).

[Nalon1 RN/EMT-P, BSN, RN]

writing an e-verbal when none is given is technically illegal and an easy way to loose your license if the Dr wishes it.

That is not critical thinking.

Asking the Dr when you call them for a specific test/treatment (anticipating their request, but not putting it in) is critical thinking.

And as brought up, many places will have protocol orders you can put under the Dr.'s name, but those are a very specific set of circumstances. I do know some nurses that say "Oh, such and such doc is OK with this order", but still not right. They may "get away with it", but still not correct procedure.

[Lennonninja, MSN, APRN, NP]

We can order a lot of things in my ICU because of protocols. We always have an intensivist 24/7 but have a lot of freedom because of our protocols.

[delphine22]

These are not protocols; these are more in line with what VANurse2010 said, about it being a decline in the pt's condition, and the nurse wanted a CXR or something to confirm her suspicions before talking to the doctor.

I still don't think it's OK. If it's an emergency situation, and there's no doctor around, and they're not returning your stat pages (who ignores stat pages from the ICU?!) that's what the code button is for -- that'll get a doctor on scene quickly if he's not returning your calls! (Other floors don't respond to codes on our unit, just the MD, since we are the home of the code team.)

[montinurse, BSN]

That sounds normal to me, especially if she's been there for so long and knows the individual doctor's expectations....

[tyvin, BSN, RN]

Docs have standing orders for everything...and it's lose; fyi :)

[vintagemother, BSN, CNA, LVN, RN]

My MD gives a **** load of verbal orders to me. Yes, I think this is because he believes I'm competent enough to use critical thinking, because he has told me as much.

I, like you, am a newbie and a stickler for not writing my own orders. However, he gives a lot of latitude. Thus far, it's working for me.

We have a system at work which allows me to communicate with him daily about medical concerns. I ASL for certain orders and he gives them. Then I implement them.

[PMFB-RN, RN]

I smile sweetly and say, "Will you be putting those orders in yourself, sir, or do you need me to write them for you?"

You call your doctors "Sir"????? Wow.

In most ICUs RN can put in orders for things like labs and xrays. Where I work an RN can pretty much order anything if there is an indication for it. These things should be covered in unit standing orders and policies.

If I call one of our ICU docs about (lets say) respiratory issues he is going to want to know what the ABG said, and to either have a chest xray to look at or expect that we would have already ordered it and it's on it's way.

Before I call a doc about a patient's chest pain I will of course obtain and 12 lead EKG and probably ordered, drawn and sent a troponin, depending on the circumstances.

This is very normal and perfectly legal. I wouldn't work in hospital where RNs did have that abiliety.

[SCBlueICU]

Like many other posters here, we have a lot of protocol driven orders. Fever protocol, electrolyte, EKG's, etc. However we have an intensivist around 24/7 and they are usually easily accessible just to run something by quick, or to come over if things are looking pretty rough. With the way our protocols are set up I wouldn't order an ABG, chest xray, KUB, without running it by our docs first. They are the ones with the authority to order and sometimes they think things I would want are unnecessary, so I would end up costing the patient if I had ordered it. Do what you feel is the right thing to do.

Also, I think our docs would be weirded out if I called any of them sir. Some of them don't like us calling them Dr. ...

[Nalon1 RN/EMT-P, BSN, RN]

You call your doctors "Sir"????? Wow.

..

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I call all males sir and females ma'am.