noting orders..... who is licensed to do this?

[eyknough]

Hi all, I have a question about physician's orders and I figured this is a good place to go! :)

I started a new position today, and a person who I was introduced to as a medical record's organizer plopped a stack of physician's orders in front of me for me to "second sign". Their policy is that two people are to verify physician's orders and two people are to initial each order in the MAR to verify the order is correct and safe.

I couldn't read the signature on the orders, so I asked one of the other nurses whose signature I was "second verifying". They told me it was the MA who noted the orders and that this MA also sometimes fills out the MAR for you to second verify as well.

I was further informed that this person is not even certified as a medical assistant, and that this person's highest education level is high school. This person also happens to be the nursing director's offspring.

I figure it's not really my duty to necessarily verify this person's credentials, but if this person is on the schedule as an MA then I figure I am safe to treat this person like an MA, which does not include seconding this person's noted physician's orders.

Is it even legal for an MA to note physician's orders or to transcribe them to the MAR? Anywhere? I thought this was the exclusive domain of the RN, nationwide. I didn't notice that any of the orders were verbal orders; they were all hand-written by the doc. So that takes some of the danger out of the equation, but I am a little confused as to how to deal with this. Perhaps I am mistaken and with the proper inservicing and training the MA can note orders? I sure know that in the N-Clex world it is only the RN who may note orders, period.

It really gets under the skin of the nurses I worked with, and even though this person has been nothing but pleasant to me it really irked me as well. I worked my little tail off in school for years to be licensed to note and transcribe physician's orders!

What do you think?

I did not second the MA's noted physician's orders.

[BluegrassRN]

I don't know about noting, but transcribing does not require any sort of license. What do you think all those unit secretaries did prior to electronic physician entry?

What sort of facility do you work at? Maas, licensed or not, seem to be able to do many things that your average joe would not be performing, like injections. Why not note orders? Noting just means they were entered into the system and implemented, right? I suspect it is a facility specific policy. If your facility says its okay, then it's okay, I suppose. Is she doing it wrong? Has she made many errors when noting orders?

[eyknough]

I haven't heard of any mistakes that have been made per se. Is noting orders something more than just entering them in to the system so they can be implemented? If that's all that was necessary (especially for fully computerized systems) then the order could just go straight into the computerized mar after the physician orders them without needing to be noted at all.

I thought a more in-depth knowledge of the medication's function was necessary to note orders. Those steps are necessary to check the physician to help keep the treatment safe for the patient. Does the MA know which labs to check to ensure the medication is safe? Interactions? Which body systems will be affected and whether adding (or changing) the medication would be safe? Which assessments will be necessary after the new order is implemented to ensure the change in medications is not having a negative effect?

Moreover, if an order is unsafe and is implemented with damaging effects to the patient are the RN's still liable for administering it after they were noted and verified by unlicensed providers? When I see an order on the MAR during med pass I assume it has gone through all the checks and balances to be indicated on the mar. This particular system I'm working with does not use computerized MARs, so during med pass I don't necessarily have handy access to labs, recent vital signs, etc. But even if I did, what about the LPN who passes meds without necessarily having the broader knowledge base to know which assessments would be necessary during med pass.

I don't know... My gut tells me "red flag". But it IS a "second" noting signature, and there is only one MA. So in effect someone with a broader knowledge base is still checking the orders for safety. And I'm not dissing on anyone in the field, but LPN's are carrying out the full functions that are usually only delegated to the RN as well. Nursing diagnoses, treatment plans, phone orders....

I haven't been an RN for a long time, and I have learned a great deal from everybody I work with. But if I'm sitting on the court stand (or in front of the nursing board), is company policy going to cover my butt? The differences in scopes of practice were made very clear in nursing school. Perhaps nursing school should be made more "real world" if it is ok, then.

Makes me uneasy....

[eyknough]

I agree that MAs are performing many functions that used to be more nursing-oriented. With proper training, blood draws and medication administration can still be safe as long as there are more knowledgeable personnel in the loop to make sure everything is safe.

If the med is ordered and noted properly, then I feel it is safer for somebody who knows how to safely administer a medication to administer it, such as an MA. But there are also RN's around to apply their knowledge and keep an eye on the patient's condition and step in and take action should something start to look wrong.

[pinkiepieRN]

Where I've worked, unit secretaries have always transcribed and entered new orders. As far as medication orders go, they scan the orders to pharmacy, where those checks and balances you mention occur.

[DoGoodThenGo]

Unit secretaries, ward clerks or whomever have been transcribing med orders since the 1970's or even before. Highly doubt many of those old school ladies had anything beyond a high school diploma.

[SDALPN]

I think you need to check out the LPN score of practice. At least in my state, we can take verbal orders over the phone and assist with care plans. We can also write orders in the MAR.

MAs in my state can't take verbal orders and we can't take verbal orders from anyone except a Dr.

You can always call the practice consultant at the board of nursing anonymously and ask questions.

I would be concerned if unlicensed people were signing anything on the MAR. If they make a mistake, we holds the license that makes us responsible.

Also, in my state they have med techs. They are allowed to give meds. That's another situation and quite scary to me!

I think you are right to question. But don't forget that LPNs can have a pretty broad scope of practice depending on the state.

[psu_213, BSN, RN]

When I worked at a hospital without CPOE--MD would write a med order. Unit secretary (unlicensed/uncertified) would record the order in the computer (which would place in on the EMAR). The written order would be faxed to the pharmacy where a pharmacist would check if it was a safe dose and make sure there was not compatibility issues (for example, the pharmacy gave me a hard time since Cipro is, in their book, relatively contraindicated in someone taking Tikosyn). The RN would verify that that the secretary correctly transcribed the order into the eMAR.

When the secretary would transcribe the order, they would date/time/initial the original order sheet filled out by the MD. This does not mean the secretary verifies the order, it does not mean he/she is saying it is a safe dose, it does not mean he/she is saying it is compatible with all the other meds the patient is taking. It is just saying that they saw the order and wrote it on the (e)MAR. To actually verify it is safe, compatible, etc. requires a nurse/doctor/pharmacist.

[meandragonbrett]

Noting an order means "I've seen it, I've taken the correct actions". It's on the MAR, you drew the labs, you called speech, etc. I think you are thinking entirely too far into what signing off a page of orders means .

[eyknough]

I think I'm thinking too far into it myself. :) Just being cautious.

It's interesting how important they made medication order noting and medications in general sound in school. I've never had to question an order yet besides perhaps informing the doc of a patient's extremely large size when a 0.1 mg clonidine was ordered.

Boy they sure scare the heck out of you about these things when we're being taught.

Still, though. There's just something about unlicensed people noting orders that gives me the heeby jeebies. I know I'm the last possible chance to catch a potential mistake when I'm passing meds, but having the question in the back of my mind whether or not people who knew what to look for were involved in at least noting the orders will give me even more cause to pause and think.

Good brain exercise, I suppose.

Psu, I agree that to verify it is safe and compatible requires a nurse, doc or pharmacist. I thought that's why it was required that a nurse note the orders even though a pharmacist is in the loop. Nursing instructors made it seem like we nurses are responsible for catching any possible mistake that can be made by any healthcare professional and ancillary staff.

Perhaps it was overkill to keep people questioning things... such as me. :)

Thank you for your input. I'll ease up on the notion of an MA noting orders, especially since they're requiring 2 people to note the orders.

[Debilpn23]

I think you need to check out the LPN score of practice. At least in my state, we can take verbal orders over the phone and assist with care plans. We can also write orders in the MAR.

MAs in my state can't take verbal orders and we can't take verbal orders from anyone except a Dr.

You can always call the practice consultant at the board of nursing anonymously and ask questions.

I would be concerned if unlicensed people were signing anything on the MAR. If they make a mistake, we holds the license that makes us responsible.

Also, in my state they have med techs. They are allowed to give meds. That's another situation and quite scary to me!

I think you are right to question. But don't forget that LPNs can have a pretty broad scope of practice depending on the state.

Thank you for posting this. I was going to post the same about the LPNs scope of practice. At my facility most of the charge nurses are LPNs and note and implement and note physician s orders.

[loriangel14, RN]

Where I work the ward clerk writes the orders out in the MAR and initials it. Then an nurse, either RN or PN, co-signs it after checking it against the order.