Nurses ordering meds

Published

Okay I have a question about ordering meds. Let's just say that you work in a clinic situation. The patient is seen by the doctor, then the doctor comes to you and tells you his orders. Sometimes the orders are written on a piece of paper but not always. The nurse then enters the orders: meds, labs procedures, etc in the computer and signs. The med orders then get e-scripted to the pharmacy. The meds can then be picked up. These orders are cosigned by the MD- but the problem is, this could be a week later. We have tried to get the providers to enter their own, but they pretty much refuse. Is this legal? Within the scope of practice?

Up Vote Up Vote ×
Specializes in Hospice, LTC, Rehab, Home Health.

The process you have described is called order transcription and yes it is legal.

Up Vote Up Vote ×
Specializes in ICU, ER.

Yes, it's legal.

When the nurse takes a verbal/phone order it is his/her responsibility to ensure s/he transcribes it correctly. I always scribble them on a piece of paper (or paper towel which is usually nearby) and always repeat it back to whoever is giving the order.

Up Vote Up Vote ×
Specializes in All Icus x Nicu/ Shock Trauma/flight nur.

Dear Ordering Meds,

Take this to your unit nursing supervisor. All the nurses have to agree to refuse to do this physicians work for him. Have the super talk to him. If he persists, simply say I'm sorry, but I am no longer allowed to do this for you. If he has any heartburn, suggest that he take it up with your unit supervisor.

then of course a policy has to be created to make it official. FLTNRSE@

Up Vote Up Vote ×
Specializes in ED/ICU/TELEMETRY/LTC.

Put your hand on the Bible and swear to tell the truth the whole truth and nothing but the truth.

"Nurse did the doctor order?" Yes

"Doctor did you order? No

Trust no one. Look after yourself. Take care of your license.

Up Vote Up Vote ×

Okay I do realize what transcription is, but in the "olden days" we also had the hard copy to follow that the doctor signed. Being it is electronic now-I realize the doctor has to go in and cosign the orders-but as I said-my concern is, if I entered what I was told, there is a mistake, patient picks up med, has adverse reaction---doctor says "I didn't order that!" or "that's not the dose I ordered-" where is the liability? When order isn't cosigned for a week?

Up Vote Up Vote ×

In ltc you get verbal orders all the time..and they are signed by md's whenever they show up.

Up Vote Up Vote ×
Specializes in ER, progressive care.

We get verbal/telephone orders all of the time. MD's hardly put in their own orders unless they are doing the med rec or something. Always read back to the provider.

Up Vote Up Vote ×
Specializes in PICU.

We used to take verbal orders constantly. Hospital policy changed and we are now only allowed to take in an emergency situation or if the dr is not on the unit.

It does come down to your word against his.

Up Vote Up Vote ×

Yes I guess it would be the same as LTC or a hospital. The orders wouldnt get signed right away there either. And the patient would be getting the ordered meds before they were co-signed in that situation as well.

Up Vote Up Vote ×
Specializes in All Icus x Nicu/ Shock Trauma/flight nur.

The point I took away for this young man's concern was that he a continual problem getting the doc to sign the order. As another nurse mentioned in her post it can be days before you get a signature and by that time he may have forgotten giving the order. Then it's your word against his. It's shamful that medical records have to suspend thier privlages just to get them to bring the charts up to date. Calling for a prn phone order to the doc I understand and vice versa. But it looks like you are placing yourself and your license in jeprody for what a doctor that thinks he is so important that he doesn't have time to write orders or dictate...oh please, they need to be accountable and responsible. I would like to make one more observation about writing orders on a scrap paper then transcribing then into the chart.First you are making double the work for yourself, second the more times an order is transcribed the chance of an error can occure. Tell the doc in a polite way that you will need to pull the patients chart, ask him/her to dictate slowly to insure accuracy, then insists on readng the orders back to get a claification form the doc.Fltnres2

Up Vote Up Vote ×
+ Join the Discussion