Nurses Refilling Prescriptions

[Garden]

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)

[Hoosier_RN, MSN]

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]

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]

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.

[NurseSpeedy, ADN, LPN, RN]

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]

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]

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.

[Kooky Korky, BSN, RN]

On 6/8/2020 at 7:46 PM, 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?

Thoughts:

1. Ask your state BON if it is legal for a nurse to do this. Make sure you talk with an actual nurse, not the first person who answers the phone.

2. I think it stinks that a nurse has to do the refill before a doctor signs a prescription. What if the doctor refuses to sign or drops dead before signing?

3. Are there any other questionable practices being done where you work?

4. Good luck. You will likely face backlash if you say you are afraid to keep doing this and decline to do it any more.

[zbb13]

I support primary care docs. The one doc has his MA fill out prescriptions for him when he’s on vacation. Including for opioids. This stuns me. He has given her parameters and I guess she’s acting under his license. I refuse to refill anything because I haven’t received a current protocol for medication refills. I value my license and I will continue sending those refill requests to the docs. I want it in writing.