Jump to content

Nurses Refilling Prescriptions

Updated | Posted
Garden Garden (New) New Nurse

Hello 👋🏼

I am a Michigan Nurse and for most of my career have worked in the hospital. Most recently I have started to work in a specialty clinic. In this clinic, the physician will delegate the ability to write orders under their name. Patients are given prescriptions for one month at a time due to the medication being weight based. So patients call every month to get a new refill. The nurse will typically get this phone call and will automatically write the order for the refill for that month and send it to the patient’s pharmacy. This order will later be sent to the provider for approval after the prescription is typically filled.

I view this as prescribing and not in the nurse’s scope of practice. When I try to find more information online, the only guidelines available are about opioids which we are not refilling.

Is it OK for nurses to authorize refills in this scenario? (I’m employed in Michigan)

mmc51264, ADN, BSN, MSN, RN

Specializes in orthopedic; Informatics, diabetes. Has 9 years experience.

you're not prescribing. The order is there, it is being adjusted to pt's weight.

You are not diagnosing and choosing the med. I assume there is a protocol or algorithm in place that you are using to determine dosages based on weight.

Hello 👋🏼

I am a Michigan Nurse and for most of my career have worked in the hospital. Most recently I have started to work in a specialty clinic. In this clinic, the physician will delegate the ability to write orders under their name. Patients are given prescriptions for one month at a time. So patients call every month to get a new refill. The nurse will typically get this phone call and will automatically write the order for the refill for that month and send it to the patient’s pharmacy. This order will later be sent to the provider for approval after the prescription is typically filled. Is this process OK?

The thing is, there's really no reason it has to be done that way and the problem (besides being a patient safety issue and also probably technically illegal) is that if there's ever a situation where the provider is looking at the order after the fact and realizes it a refill probably shouldn't have been authorized for one reason or another, they might cause trouble over signing it, or say they never authorized the refill and refuse to sign it. They could try that; not to say they will. It just puts you in a bad position.

Here's a sort of similar situation (although in this case the meds were refilled by a policy that included a "standing order" to refill meds).

OP, why must the patients go through this every month? What kind of meds are we talking here?

And, no, in reality the doctor cannot delegate prescribing authority to you under the pretenses that s/he will "cover" you (sign for it later). You cannot prescribe medications under your name or anyone else's. It is outside your scope of practice. I would advise obtaining a proper order to refill for each of these instances--and if that's going to be done then the physician might as well be messaged through the practice's EMR and s/he can enter the order for the refill.

Thank you for the feedback.

This is for a Hemophilia Clinic. Medications are weight based so the monthly refills keeps track of the patients weight and the potential for dosage change. This also keeps track of any bleeds the patient may experience. If the patient has had any recent bleeds/weight changes THEN the provider is notified and involved in the refilling process. Otherwise if the patient had no recent bleeds or any weight changes the medication is then refilled by the RN but the physician is not involved until it is already ordered. Thoughts?

My experience in Michigan suggests that there are standing orders which outline what the prescription should be according to the known and measured criteria. The RN is prescribing nothing, only executing the physician orders according to the assessments and judgements which are well within the professional duties of the license.

Please look for the standing order set.

dream'n, BSN, RN

Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych. Has 28 years experience.

Isn't this kind of what Coumadin Clinic nurses do? They see or speak with the patient, get an INR, and adjust the anti coagulant dosage if needed based upon set criteria. The provider is only notified for problems or questions.

1 hour ago, toomuchbaloney said:

My experience in Michigan suggests that there are standing orders which outline what the prescription should be according to the known and measured criteria. The RN is prescribing nothing, only executing the physician orders according to the assessments and judgements which are well within the professional duties of the license.

Please look for the standing order set.

With the clarification made available via thread merging, I agree.

CharleeFoxtrot, BSN, RN

Has 10 years experience.

7 hours ago, dream'n said:

Isn't this kind of what Coumadin Clinic nurses do? They see or speak with the patient, get an INR, and adjust the anti coagulant dosage if needed based upon set criteria. The provider is only notified for problems or questions.

Exactly my thoughts. I work in a practice in Michigan and the coumadin dosing is done by nurses with some extra training. They have specific parameters and of course ask the doctor for guidance when needed. They are acting under a standing order set.

kp2016

Has 20 years experience.

10 hours ago, Garden said:

Thank you for the feedback.

This is for a Hemophilia Clinic. Medications are weight based so the monthly refills keeps track of the patients weight and the potential for dosage change. This also keeps track of any bleeds the patient may experience. If the patient has had any recent bleeds/weight changes THEN the provider is notified and involved in the refilling process. Otherwise if the patient had no recent bleeds or any weight changes the medication is then refilled by the RN but the physician is not involved until it is already ordered. Thoughts?

The key to this situation is written standing orders. As long as you have a very clear standing order / policy this is fine. You are gathering a recent nursing history and implementing the Doctors orders based on clearly defined parameters. Any situation that falls outside of the written parameters should be referred to the Doctor for review.

I have worked in many units where the nurses ordered laboratory tests or gave patients instructions to withhold X medication for Y number of days prior to a given procedure. We had a very clear written policy with parameters for orders and for medications. It was laminated and beside our computers / phone lines for easy access. If your clinic doesn't have laminated cards at your work station consider working with your manager/ educator to make it happen.

^ Agree, and in no instance should any of this be thought of as ordering something under someone else's name. That isn't really what is happening (thankfully). 👍🏽

Hoosier_RN, MSN

Specializes in dialysis. Has 28 years experience.

12 hours ago, Garden said:

Thank you for the feedback.

This is for a Hemophilia Clinic. Medications are weight based so the monthly refills keeps track of the patients weight and the potential for dosage change. This also keeps track of any bleeds the patient may experience. If the patient has had any recent bleeds/weight changes THEN the provider is notified and involved in the refilling process. Otherwise if the patient had no recent bleeds or any weight changes the medication is then refilled by the RN but the physician is not involved until it is already ordered. Thoughts?

My thought: what if their scale is wrong, or the like? I'm not sure I'd be up for that method. It leaves room for error, especially a new patient. Established patients probably get it. I'd be too worried about a mess up

Katie82, RN

Specializes in Med Surg, Tele, PH, CM. Has 39 years experience.

While I was working as a Practice Administrator in a Family Medicine Practice we introduced Allscripts. Under certain circumstances, I was authorized to fax refills on medications that had a 12 month order. These were mostly chronic meds like blood pressure, PPIs, etc. I was not allowed to issue a new script. The doc always received a notice that I had faxed a refill. This was done in accordance with a written protocol, Never refilled if the patient was having problems or had questions. System worked well for us.

FolksBtrippin, BSN, RN

Specializes in Psychiatry, Pediatrics, Public Health.

On 6/8/2020 at 6:52 PM, Garden said:

Hello 👋🏼

I am a Michigan Nurse and for most of my career have worked in the hospital. Most recently I have started to work in a specialty clinic. In this clinic, the physician will delegate the ability to write orders under their name. Patients are given prescriptions for one month at a time due to the medication being weight based. So patients call every month to get a new refill. The nurse will typically get this phone call and will automatically write the order for the refill for that month and send it to the patient’s pharmacy. This order will later be sent to the provider for approval after the prescription is typically filled.

I view this as prescribing and not in the nurse’s scope of practice. When I try to find more information online, the only guidelines available are about opioids which we are not refilling.

Is it OK for nurses to authorize refills in this scenario? (I’m employed in Michigan)

We do this all the time. It's not out of our scope to authorize refills.

However, I work in community psych, we have a daily morning meeting with the whole team including the NP, I know all my patients very well, and I'm very confident in who actually needs meds refilled and who shouldn't get a refill for whatever reason.

I'm also in a state sponsored program that specifically outlines this as my duty.

If I left all the refilling to our NP she would not have the time to do the stuff we really need her to do.

Edited by FolksBtrippin

NurseSpeedy, ADN, LPN, RN

Has 18 years experience.

I am assuming there is a protocol for the refills. Anything that doesn’t fit the protocol I would run by the physician. I spent the first 17 years of my career in mostly hospitals-I noticed a big difference between hospital and office protocol with med orders. Refills I’ve dealt with are usually chronic use-and not controlled-scripts. We have protocols in place to follow for allowing or denying a refill

CommunityRNBSN, BSN, RN

Specializes in Community health. Has 3 years experience.

Refilling meds is a big part of my FQHC job. Our protocol is that nurses can send 30 days of chronic medical meds (statins, BP meds, levothyroxin, etc). Nothing psychiatric, nothing for pain (even Advil). After that 30-day refill, the patient has to be seen by the provider for additional refills.

LovingPeds, MSN, APRN, NP

Specializes in Clinical Pediatrics; Maternal-Child Educator. Has 11 years experience.

On 6/8/2020 at 5:52 PM, Garden said:

Hello 👋🏼

I am a Michigan Nurse and for most of my career have worked in the hospital. Most recently I have started to work in a specialty clinic. In this clinic, the physician will delegate the ability to write orders under their name. Patients are given prescriptions for one month at a time due to the medication being weight based. So patients call every month to get a new refill. The nurse will typically get this phone call and will automatically write the order for the refill for that month and send it to the patient’s pharmacy. This order will later be sent to the provider for approval after the prescription is typically filled.

I view this as prescribing and not in the nurse’s scope of practice. When I try to find more information online, the only guidelines available are about opioids which we are not refilling.

Is it OK for nurses to authorize refills in this scenario? (I’m employed in Michigan)

Yes, this is okay and acceptable. I can give you an example of a similar inpatient scenario. Working inpatient pediatrics something as simple as ibuprofen is weight based. Our order would be something like "ibuprofen 10mg / kg every 6 hours PRN for pain" or "ibuprofen for weight and age every 6 hours PRN for fever". It was up to us to write the dose and update it as needed if there was a large weight change over time. For age meaning not to exceed the recommended dose for that age or to use the adult dose if adult weight. For instance, if the child was hospitalized for 6 months and gained 5 pounds in that time, the dose could be updated to reflect the order. It's not prescribing to do that. The order itself is weight-based. Joint Commission even saw these orders and said nothing about them on numerous occasions.

What you are doing is updating an existing order to reflect a current weight. This is very common in medical fields or with medications that require weight-based dosing. You are not technically prescribing or writing an order as you have an order for the medication in place by a provider only requiring you to reflect current weight in dosing.

With chronic diseases, the providers often prescribe with the intention for these patients to be on this medication until they see them at the next follow-up unless complications occur or they specify for X amount of time. Refilling medications as you are is not uncommon in these types of situations usually based on an office protocol put in place by the providers. As a provider, my nurse often refills medications using a protocol set by our office as to which medications can be refilled and for how many times before we need to see them back. I as an authorized provider designate for her to refill the prescription for me based on the protocols we have set. She sends the refill in my name to the pharmacy because I am the authorized provider whose protocol she is following. She is not writing my orders, she is independently following my orders. This protocol helps me. If I had to approve every refill myself before it went to the pharmacy there could be delays in people getting their medications. I often times don't see these notifications until the end of the day or the next day depending on how busy we are in the office.

Edited by LovingPeds