Need your opinion, please

[ravensrn]

A few weeks ago a nurse was fired for writing a doctor's order. The order was for an OTC medication. When the doctor found out she wrote the order without asking him, he called the state nursing board and JCHACO. State board took this nurse's license away - permanently. JCHACO is "investigating" (going over charts, etc. etc.)

Management tells us to call the doctors for ANY order, no matter how "trivial". A few days later we're told "Well, you know that he (the doctor) never fills out the pre---- orders, but you know what he wants...." Or else you're advised to go to a unit where the doctor is well-known and the nurses there will tell you what boxes you should check - based on the doc's preferences/habits.

Ok, so here we have mixed messages.

I want to stop writing orders for the doctors who are too lazy to call you back, for the doctors who tell you "You know what I want". So I started to call them ("Dr.--, you wrote transfer orders. Do you want to continue the same meds?")

Many nurses say they will continue to write the orders for the doctors they know well, those who will not raise a stink about it. So I'm now in the minority, I'm the "stick in the mud", and I feel torn. What would you do?

We haven't heard the hospital official position on this dilemma. It does appear to me, however, that they're not willing to sit with the medical staff and tell them to start doing their job. I'm sorry, but I do not believe for a moment that a doctor will stand behind you if "something" should happen. The way I see it, when push comes to shove, the doc will stand behind you to kick your behind in order to save his/hers.

Sorry for the long post. What do you suggest I do?

[RN1982]

Writing doctor's orders without the doctor's direct input is a BIG NO NO. I don't care how well I know that doctor, I'm not writing orders for him. I don't get paid to do his job. He sure isn't paying those nurses to do his either. You went to school to earn that license and you MUST protect it.

[uraqt2]

I don't get paid to do his job. He sure isn't paying those nurses to do his either. You went to school to earn that license and you MUST protect it.

I agree with you 100%. I've said this so many times I've lost count. I've upset numerous docs when I've told them that I don't get paid to do their job and I'm not about to guess what they want ordered. You NEVER write an order without the doc knowing about it no matter how well you know them.

[santhony44, MSN, RN, NP]

If they want standing orders, let them write them. If management will acquire a backbone, that will happen. If the physician habitually doesn't use the available standing orders because he or she is accustomed to having them done by the nurses (guessing what's wanted) then when staff quits enabling that behavior, the behavior will stop.

The bottom line really is that it is your license and that you must protect it.

What happened to the nurse in your example is extreme but it can happen.

[classicdame, MSN, EdD]

JCAHO also requires verbal order readback (and telephone order). The nurse who does not follow these steps is setting herself/himself up for real problems. Institute chain of command when needed. Risk management should be contacted and should educate the medical staff.

[widi96]

I always call a doc for any order. I will call and bug them about a diet order, etc. Usually don't bug them about activity level or VS frequency (activity level I usually assess the pts capacity first and VS frequency we have standard protocol for all new admits - even if the doc write Routine VS, they get them Q4 for at least the first 24 hrs of hospitalization). Now granted - the nurse should not have written the order without talking to him (he is protecting his license too), but I think I would call that doc for the smallest of things - VS frequency, activity, etc. Just to have my i's dotted and t's crossed. I would call for anything - management is not going to save your license for writing med orders without the docs approval.

[bagladyrn, RN]

Agree with all the other posters - Don't do it! If managers are telling you to do this, tell them to put the policy in writing, then you will run it by risk management and the BON. Don't worry about having to follow through on this - no way will anyone put this in writing - which will tell you exactly how legal it is.

[ravensrn]

I want to thank everyone for the input. I spoke with my manager today. She said the medical director and administration are dealing with this issue and hopefully "something" will be made available in a couple of weeks.

She said the doctors are now beginning to fight among themselves (obviously many of them do not want to be called at all hours of the day - and night!)

She also said that we (the nurses in my unit) will be covered by ACLS only if the patient crashes. For example, if a patient's blood pressure drops, we can no longer give fluids and start dopamine - like we've always done. All we can do is tilt the bed and give fluids. No dopamine unless the patient actually crashes and we must open the cart.

Also, no more IV pushes of morphine for chest pain or prior to pulling sheaths following heart caths unless there is a written order.

I have a feeling this mess is going to take a while to sort out! Perhaps Dr.---- was correct when he said "You know, if some of these doctors don't smarten up, we may end up losing some patients..." I find this quite distressing. How can I sit and watch my patient die because the darn doctor didn't write orders or refuses to call back???

[ukstudent]

How can I sit and watch my patient die because the darn doctor didn't write orders or refuses to call back???

You document very very well all the attempts made to contact him/her and then go up the chain of command. Someone is above him/her. Call your supervisor and let them know that you are going to need the medical director to call back. The Doc's will get the message about prompt calling back if the medical director is being called at any time but especially if at night.

If anything happens that is a close call due to delay in calling back, make sure that risk management knows about it. Risk management has a way of being isolated and not knowing just what is going on, on the floors and units.

[tutu123]

I refuse to wrtie verbal orders for a dr that is standing right there and telling me what they want. In a code or emergency this is ok but, I always have the dr write to orders. Some facilites that I have worked at have nursing orders that you can write. But the lazy dr that say write what ever you want need to do their job. We as nurses have enough to do and we should not enable their bad behaviour. The dr's are just as busy as we are. If the physican takes too long I will write a note in the chart to explain the delay of service.

[uraqt2]

As much as I don't like to write orders for doctors standing right there I must say sometimes it's easier to just write the verbal and make them sign it before they leave. I once worked with a doc that couldn't even read his own handwriting so if there were any questions about the order you ended up getting a whole new page of orders. We nurses decided to just take his verbal orders and make him sign them. Sure beat the alternative.

[santhony44, MSN, RN, NP]

As much as I don't like to write orders for doctors standing right there I must say sometimes it's easier to just write the verbal and make them sign it before they leave. I once worked with a doc that couldn't even read his own handwriting so if there were any questions about the order you ended up getting a whole new page of orders. We nurses decided to just take his verbal orders and make him sign them. Sure beat the alternative.

That works, until the physician looks at you and says "That's not what I said" and refuses to sign.

That happens, more than you might think.

A lot of facilities have policies that state that nurses may not take verbal orders except in emergency situations (if the physician is intubating a patient, for example) or over the phone.