nurses writing admission orders

[katydid1161]

hello,

i am seeking some advice to help me deal with a situation at my workplace involving rns writing admission orders. i began working for an inpatient rehab hospital in pa 6 months ago and am uncomfortable with the routine practice of rns writing admission orders. this practice has been going on long before i started working there. the reason behind this practice is so that the attending physicians do not have to come into the hospital in the evening (when 95% of the admissions take place). we are expected to write med orders (based on what the patient was receiving at the previous hospital, ltc or home), lab orders, diet orders, etc. once the orders are researched and written by the rn, he/she calls the attending md and reads the orders, thereby signing the orders as a telephone order.

i and many other of my nursing colleagues are very uncomfortable with this practice, as we feel it is not within our scope of practice to be writing orders, potentially compromises patient safety and puts our nursing licenses in jeopardy.

i have tried finding information within pa's nursing scope of practice, but am unable to find much to support my concerns.

does anyone have any input and/or advice to help me?

[leeae85]

I'm pretty sure at the rehab nursing home where i used to work used to do the same thing, and we never had any problems with it. Whenever the patient was d/c'd from the hospital, on his d/c summary there was a specific list of d/c meds and d/c orders, and we would write those out as admit orders, call the on-call md/np and they would approve, and usually add some lab work to the orders. I figured that was just standard practice.

[Xbox Live Addict]

I'm pretty sure at the rehab nursing home where i used to work used to do the same thing, and we never had any problems with it. Whenever the patient was d/c'd from the hospital, on his d/c summary there was a specific list of d/c meds and d/c orders, and we would write those out as admit orders, call the on-call md/np and they would approve, and usually add some lab work to the orders. I figured that was just standard practice.

This was a standard practice at any NH I worked at, if a new resident were being admitted from home. The admitting nurse would review the medication list from home, transcribe it to an order sheet, get the physician to approve via telephoen order, and the physician would sign it on his next visit; generally at that time, s/he would order a set of labs to obtain baselines (CBC, CMP/chem 12, T4, TSH).

[morte, LPN, LVN]

yup, if it were during the day, might fax them to the office and get them signed that way........if it is a particularly complex or confusing case, i might tell the doc, or pass on to next shift, that the doc needs to come in the next day and look thru themselves, instead of waiting till "the next" visit....

[Straydandelion]

There used to be something similar in orthopedics depending on the practice group and diagnosis from ER. Pre hip fracture routine orders etc. though the floor had those routine orders written in a procedure book. Therefore you would write, per routine hip fracture orders for Dr. so and so then write the admission orders. The doctor when came by in the morning would sign and add other orders. If uncomfortable with it, possibly get the docs to have a set of "routine" admit orders?

[Hilinenursegrl]

I don't see any problem with it as long as the orders are signed off TO or VO.

[snowfreeze, BSN, RN]

I worked at a facility that did simular, often the admitting doc for the nursing home was the one who wrote the discharge instructions from the hospital. We would call doc to let them know patient arrived and repeat discharge/admit orders along with usually asking a few questions about labs, diet etc that might have been missed. Admissions to nursing homes are much more work for the nurse than those to a hospital in my opinion.

[NotFlo]

I'm not seeing what the problem is as long as these orders are being read off to and approved by the MD and then signed as TOs.

It isn't like the RN is making up meds or diets, the RN works from the hospital discharge summary and simply transcribes what is ordered on that, and it is up to the MD to either accept or reject or change these orders.

In rehab/LTC it might be a day or two until the patient's doctor comes into the building to see the patient.

[rockstarn]

Yep, this is "usual." As long as TO/VO signed off by MD thereafter II believe it has to be within 24 hours) - it's good.

If I may ask, what in particular about this practice makes you and the other nurses uncomfortable? The MD IS being notified of all the meds, right? (It would be a completely different story if nurses were writing "TO" per an MDs request when, in fact, it wasn't a TO...

[Thornbird]

It is standard practice in non-acute care (sub-acute, rehab, LTC, home care) to take orders from referral/discharge summary and then get a telephone or fax order to implement. Usually routine orders like therapy evals and prn meds such as Tylenol and MOM are added for the MD approval at the same time.

[NurseKatie08, MSN]

I'm not seeing what the problem is as long as these orders are being read off to and approved by the MD and then signed as TOs.

It isn't like the RN is making up meds or diets, the RN works from the hospital discharge summary and simply transcribes what is ordered on that, and it is up to the MD to either accept or reject or change these orders.

In rehab/LTC it might be a day or two until the patient's doctor comes into the building to see the patient.

I work rehab--we review the referral from the hospital, call the MD, read the orders and take down any changes or additions and write it out as a TO

e.g. "Admit to Medicare certified bed for SNO, SNS & SRS. Expected length of stay not to exceed 30 days. All orders verified with Dr. Jones c the following modifications: blah blah blah T.O. Dr. Jones/NurseKatie08."

We also have templates on our computer system for common orders such as tylenol, bowel protocol etc, and ask the doc if those can be added. I don't see anything wrong with taking a T.O. for admission orders---in my setting, the doctors are not always in house, so there is no other way for us to proceed with an admit besides calling them. Obviously, if the nurse is making up orders on their own, that is a problem.

[Babs0512]

I don't see any problems, so long as no meds or treatments are given until the orders are verified with a doctor.