Noting orders VERY late...legally, what happens?

kakamegamama · Feb 3, 2011

Talk to your risk management department for starters.

BabyLady, BSN, RN · Feb 3, 2011

UGH!!! The other day, I found new orders on my patient NINE HOURS after they'd been written. I'm sure I don't need to explain ALL the reasons I never saw the chart---you all already know
What ticks me OFF is of course, the patient could have been affected negatively,
AND.....what about if I were to go to court? I can imagine the lawyer would do everything
to discredit me...
(laywer)."NINE hours???......you didn't see these orders for NINE hours?".....
(me) "but, first PT had it, then the RD had it, then speech had it, then OT had it, then the physicians had it, then the case managers had it......then the chaplain had it...."
(Lawyer) those are not valid reasons.....YOU were still that patient's nurse!
(Me) Yes; however, I also had MANY other patients and I ran all day! There's no way I
could know about those orders without someone TELLING me! Is it my fault we don't have a more ORGANIZED system, perhaps, COMPUTERZED orders!!???
(Lawyer) Again, You were the nurse, it was YOUR responsibility
(Me) Thanks, you have now confirmed my choice to work at Walmart!
But seriously, I want to know the LEGAL ramifications of this. Where do I start? Would it be under my state's Nurse's Practice Act??? Looking back, I wish I had done what I usually do----COVER MYSELF in my Nurse's Notes!!!!!---I *wish* I had written "new orders received and noted late due to several ancillary personnel had possession of the chart throughout the day."

First, don't blow this out of proportion...you already have it in your mind that you are going to get sued and end up in court.

Physicians do not chart with frequent orders...in many facilities it is only once per day.

In our facility, when they do rounds, we have a system where they have to "flag" the page on the chart (pull it up in the binder about 1/3 the way)...that way we can see there are new orders.

Physicians are told if they do not do this...they either need to tell the nurse verbally or risk it not getting seen until later.

We are given the authority, by our Medical Director, that we can call that physician resident...whatever hour of the day or not, to clarify orders. We have a problem with a resident coming around, entering orders, the nurse signing off on them, then the resident coming back and writing MORE orders and never telling anyone.

There is a spirit in the law called "reasonable expectation"...what is considered "reasonable" for an able nurse to do....not super-nurse...a reasonable nurse.

It is NOT reasonable, that every time you walk away from the chart and it leaves your eyesight, that you go back and check it for new orders. That is NOT considered reasonable.

What is more reasonable, is that instead of you checking every time you walk away on the 5, 8, 10 or more patients that you have, is when they enter new orders at odd times, that you have a system in place for the nurse to be informed.

But I can tell you now...if you write in the chart that there were personnel issues....which can give an attorney a field day with blaming the hospital for short staffing, you won't have to worry about any of it, because that can get you fired....that is NOT something that is supposed to be charted.

However, on a side note...if the physian's and other disciplines are coming around and grabbing charts, it IS your responsibility (and therefore, reasonable) to see what was written. If you never looked at the chart all day after they did rounds...then yup, that would be your fault.

In our facility, the chart never leaves the unit...and we will take it away from PT, the RD, and especially the chaplain in a NY minute, because orders written by a physican TRUMPS everything else.

INLPN93 · Feb 3, 2011

That is why nursing management should arise from that chair in their office and do rounds with the MD.

Then, even if they were too lazy to note off the orders it could be brought to your attention that the orders were there to begin with to deal with in a timely manner. And also come up with a way to alert depts to LEAVE THE CHART ALONE due to orders on the chart to deal with!

It really should become mandatory for all nursing management to meet on the floor hours to keep their jobs. That way they really get & understand what is being asked of their nurses. It would really help.

SnowboardLovinRN · Feb 3, 2011

If you develop a system its easier. I check each of my charts at regular intervals... and before I go to break to make sure I am not missing meds or orders. I'll check about every 2 hrs, and of course after I see a MD rounding on that patient. If its a busy day I MAKE SURE to check each of my charts before I sit to chart, so I can clear my head of tasks left to do. Often times when I flip open the chart to admin meds I will check then too.

You are the RN, and ancillary services should have second priority to the chart. If they ask to see a chart you have yes, but let me double check it really fast. And run through the chart, checking orders and meds before you had it over.

Check check and check! Thats all I can recommend, and develop a system. If you do things in a certain way every time you will find your day gets a little easier.

rn438 · Feb 3, 2011

How about some communication ? The doctor should let you know he left orders, especially if they are ASAP or stat orders . If it didnt cause any harm to the patient , dont worry about it but I would definitely discuss with your manager how to avoid this in the future

nervousnurse, ASN · Feb 3, 2011

Thank you for all your replies, I really appreciate it and I agree with everything that everyone said!

Where I work, the way we deal with charts is TERRIBLE on certain days. The charts DO leave the nurses' station for a couple HOURS because they have meetings to discuss all the patients and everyone needs certain papers to fill out, so the charts are just GONE. This is also terrible because sometimes we have questions that only the chart can answer---labs, progress notes, etc......UGH!

Me thinks I'm going to chat with our risk manager about this......I still cannot believe the charts leave the floor for HOURS----!!! :confused: :down: :mad:

LaurenBoog · Feb 3, 2011

I wrote about having the same situation in one of my posts (my post was about emergency situations--I am literally in the room with the patient the whole shift and the MD writes orders for something and lays the chart who knows where, and then I never see the orders and I feel like this definately affects my nursing care).

All I can say is, now that you have been through that situation, you will know to keep an eye out for the "wandering chart" in the future. Like the other posters said, create a system to remind yourself to check every chart at certain intervals (that is what I'm going to do in the future even if I don't feel like I can step away from the bedside).

I had to laugh during your imaginary deposition with the imaginary prosecuting attorney when you were explaining why you couldn't check the chart. That was hilarious/so true/ my worst nightmare at the same time!

Good luck!

rn438 · Feb 3, 2011

we used to have a sign the doctors would turn over that was red that said "new orders" , it hung outside the patients room . Also- If someone took the chart they had to leave a not - chart is with " ____" . It really is not OK to have the chart gone for 8 hours - its a safety issue!

Kyrshamarks, BSN, RN · Feb 3, 2011

When you are noting orders are you are doing is actually legally acknowledging that you have aware of the order. Thus that is why we do chart checks to MAKE SURE ALL ORDERS ARE SEEN. There is no rule that orders have to be acknowledged inmmediately, many times it is hours after the order is written that it gets acknowledged. If it is an emergency then the doc needs to tell you the order as well as write it.

ChristineN, BSN, RN · Feb 3, 2011

Thank you for all your replies, I really appreciate it and I agree with everything that everyone said!
Where I work, the way we deal with charts is TERRIBLE on certain days. The charts DO leave the nurses' station for a couple HOURS because they have meetings to discuss all the patients and everyone needs certain papers to fill out, so the charts are just GONE. This is also terrible because sometimes we have questions that only the chart can answer---labs, progress notes, etc......UGH!
Me thinks I'm going to chat with our risk manager about this......I still cannot believe the charts leave the floor for HOURS----!!!

That is crazy! Do you have a chart sign in/sign out book at least that way you know where the chart is? If not they should print out duplicate copies of labs or whatever they need to take with them.

CoffeeRTC, BSN, RN · Feb 3, 2011

Ugh...is this long term care?

Something like this happened to me before and now I'm known as the chart Nazi. Yeah...those who work with me know they better not be taking the chart off the unit for a lenghth of time without telling me. If they do, and they are a nurse...they betta be taking off that order and dealing with it. If it is someone else. (PT, OT, etc) they let me know or make a list. When I get the free time to check the charts or know that the doc was in, I run and check those charts.