Nurse Practice Act question, can RN's write orders?

[2Cats]

I am wondering if RN's that work with a surgeon are able to make postoperative rounds and co-sign orders (surgeon's name/Rn's name) and write in progress notes or is this a breach of the Illinois Nurse Practice act?

The RN's come in the morning and make rounds on the patient, do an assessment, write a SOAP note in the progess notes and then write orders such as "out of bed" "discharge today", etc. And write these orders cosigned. The MD will come around later in the day and co-sign the orders and the progress notes. I would think this would be practicing as an APN but an APN I would not think would cosign orders working under his/her own license. Any help is appreciated.

Does anyone have any similar issues such as this at their current place of work?

[rn undisclosed name]

I would think not. However, I don't know the relationship between the nurse and the doctor. Perhaps they had a discussion on the patients and that doctor is fine with the d/c if certain requirements are met. SOAP notes are generally not written by RNs (at least not in my experience). Back when I took telephone orders I would NEVER take a telephone discharge order. I always made the doc write that one.

[paacollins]

That doesn't sound right to me but I am NC and IL may be different. Sounds a bit out of the scope of practice though.

[traumaRUs, MSN, APRN]

In IL, an RN can write a telephone order and sign A. Jones, RN/B.Smith, MD and be okay.

It is not okay for RNs to write soap notes and then give orders unless the MD is present. I would bet if the hospital credentialling office/med board were to find out this would stop pronto.

This is not safe practice at all.

Me thinks the surgeon should ante up the $$$ and hire a mid-level who can legally perform these services.

[mum2kaza]

I agree in Ilinois no SOAP notes unless you are an APN..... I used to triage for te Family Physician I worked for on the weekends and had standing orders to use.... That does not sound like it is safe or legal....

[Cajun Nurse]

the answer is no. the medicare conditions of participation state that medicare partients are under the care of a md/do. most facilities apply these standards to all patients as it is the most exacting standard. i had a discussion with the lead surveyor in cms region x and here guidance was that for inpatient orders all midlevel orders must be co-signed to demonstrate physician involvement. believe me i would not have dreamed of inquiring about an rn writing an order after our conversation. oh i am an rn compliance analyst so this is my life to answer these questions.

[simvee]

It sounds like they're writing them as telephone or verbal orders, considering they're later cosigned. It may be a bit hazy to call it a phone or verbal order when there was no specific telephone call, but can you take a blanket verbal order covering all patients? That's kinda like a hospital protocol; we "write orders" based on a heparin nomogram, we don't call the physician every time we need to adjust the dose.

[Cajun Nurse]

during my army career i was an intensive care nurse for ten of those years. at eisenhower army medical center our physicians would write our order for vasopressors, insulin drips and heparin as titrate to a specific value depending on the drip and call me if …. that is how we managed therapeutics that are as we would say fluid. there was no need to write orders for changes, but our nursing documentation had to be very complete and precise.

in my world verbal orders are a serious concern. the expectation of cms is that verbal orders are accepted by licensed personnel (nurse, pharmacist). cms put this wording into 42 cfr 482.23©(2)(i) if verbal orders are used, they are to be used infrequently. this is in the cms world is recognized as a safety issue. cms’ approach is if a patient needs a lot of verbal orders maybe the physician needs to be present directing the care. it is interesting that cms put this regulatory line only in the nursing conditions of participation. this would lead one to think that nurses are, as the patient advocate, expected to tell the physician enough i am not taking another verbal order because i need you here. i realize the problems that may cause, been there done that.

lastly a verbal order must be spoken and the nurses in my hospital will only take telephone orders. if the physician is present they are handed to chart. and the requirement for the authentication of that order is actually written as promptly and failing that, within 48 hours. i have had reports from fellow compliance professionals that their facility was cited by cms when the verbal order was signed within 48 hours because the issue at hand was critical and the physician should have come in after giving the order to check on the patient. some may say that is unreasonable. i personally have sat with cms folks and they can be very insistent.

reference: state operations manual, appendix a survey protocols. regulations and interpretative guidelines for hospitals.

this is a lot and i hope you find it helpful. richard

[traumaRUs, MSN, APRN]

As a mid-level in IL, I do not need my orders on hospitalized pts co-signed.

[Herold]

Hi,I completed my diploma in nursing here in India and now I want to study post bsc nursing(degree) in USA part time.SO please guide me where to study and what to do..