nurses writing their own orders

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I have recently started working in a LTC facility (previous experience was in a hospital setting as an RN primary care provider). It seems as if all the nurses here T.O. orders for the patients (LPN and RN alike). I was never specifically told that I was allowed to do this but it seems to be tha accepted practice here. Is is allowed under the nursing practice acts in my state of CT. Please advise. My DNS will not address this issue directly with me. Thank you.

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Specializes in SICU.

I am not sure that I understand what you are asking. Are the nurses getting telephone orders for the pt's or are they just writting their own orders without talking to any Doctor?

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Specializes in RN, BSN, CHDN.

Thanks ukstudent I was wondering the same thing myself

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Specializes in trauma,cvicu,micu.

My advise is to check with your nursing board. In my state and hospital it is accepted. When i worked in the ICU, we would get T.O. and V.O. all the time. As long as it is properly documented I dont see an issue, but again check with your state to see if it is accepted. I work in trauma/er now, so it isn't an issue. I hope this helps. good luck!

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Specializes in LTC.

I am in NC...I work in LTC and we all take telephone and verbal orders from the MD. I have known and seen many nurses write orders for things without talking to the MD first...such as UA C&S, I recently saw one write an order for senokot po qd for a pt b/c his wife said he took it at home. They wrote the order and put it in the md book that they had done it. Our Md is usually very lenient as far as ordering UA's but I dont do that...I put it in his book or if I have to call him Ill ask him if its ok first and then I document about every single order I ever get and I note where it came from. I have mentioned in the past to my DON "why dont we just make a protocol for UA's and some xrays so we dont have to go through the MD all the time?" she said "thats a waste...we dont have time for that". umm...why not is my ?. I think if we have protocols for phenergan, tylenol, etc....why not the others? If someone shows or c/o 2 s/s of a UTI or if they have a fall and start c/o leg or hip pain....one would think that a protocol would be founded. Otherwise...check with your BON and see what you find there.

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Specializes in Geriatrics, Transplant, Education.

I've also seen some nurses in my setting (rehab within an LTC facility) write orders without talking to the doctor first--I'm not comfortable doing it. The most I will do is actually obtain a urine or stool sample for some one who has s/sx UTI or C Diff & page the MD to let them know--most all of them are thankful for letting them know and say that I can go ahead and write the order/send out the spec.

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So in other words, instead of calling the MD and getting a telephone order, they pretend they called the MD and got a "telephone order." There comes a point with some doctors that they'd rather you just say you talked to them and they'll say you talked to them than actually bother with the conversation. When in doubt, call the doctor. Optimally, you'd have protocols in place instead of these unspoken ones, because if something happens, it is your butt on the line. But I can't say I've never been VERY close to a situation of a nurse telling a doctor that they had given a verbal order when they were busy elsewhere and them happily signing off on it.

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I have recently started working in a LTC facility (previous experience was in a hospital setting as an RN primary care provider). It seems as if all the nurses here T.O. orders for the patients (LPN and RN alike). I was never specifically told that I was allowed to do this but it seems to be tha accepted practice here. Is is allowed under the nursing practice acts in my state of CT. Please advise. My DNS will not address this issue directly with me. Thank you.

I work in SNF and that is a very accepted practice, depending on the doctor and the order. We write T.O.s regularly for minor treatments(calmoseptine, dry dresings, monitoring and recording O2 levels, Nystatin...) We would never write an order for any "real" meds... Most but not all doctors will allow it. To my knowledge it is pretty common at any facility. We call for orders for little things like Immodium though. We give nothing P.O. without a real T.O. Dont start Caths..

No doctor wants to be awakened in the middle of the night just to give permission to apply skin prep to a patients heels... Our DON as well as MDs that allow it will tell us to do it. If the state investigates it, there is nothing they can do if both the MD and the nurse say it was a real T.O. I have had the DON write T.O.s for Haldol and Ativan injections for a patient and the MD is OK with it because they know the patient and have actually written those same orders for the same patient and trust the DONs judgment.

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No doctor wants to be awakened in the middle of the night just to give permission to apply skin prep to a patients heels... Our DON as well as MDs that allow it will tell us to do it. If the state investigates it, there is nothing they can do if both the MD and the nurse say it was a real T.O. I have had the DON write T.O.s for Haldol and Ativan injections for a patient and the MD is OK with it because they know the patient and have actually written those same orders for the same patient and trust the DONs judgment.

I'm still a student, so I'm not making any accusations or anything here so please don't get upset, I'm simply curious. This seems to me like taking a HUGE risk. If something does happen, and an investigation is carried out, how many of you think that MD will actually back you up? Do you really think they would? I mean even if it's common practice, it seems it would still be easy for something minor to happen and then oops, there goes your license for practicing outside your scope (by writing orders). Again, I have no idea, I'm just curious so if I run into this in the future, I have a better idea of what kind of risk I am or am not taking. TIA for any responses!

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Yes it's a risk. But so is every other shortcut we take to get our jobs done. It's a matter of deciding what risks are worth taking to get through the day. Because doing everything by the book will never get everything done.

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I'm still a student, so I'm not making any accusations or anything here so please don't get upset, I'm simply curious. This seems to me like taking a HUGE risk. If something does happen, and an investigation is carried out, how many of you think that MD will actually back you up? Do you really think they would? I mean even if it's common practice, it seems it would still be easy for something minor to happen and then oops, there goes your license for practicing outside your scope (by writing orders). Again, I have no idea, I'm just curious so if I run into this in the future, I have a better idea of what kind of risk I am or am not taking. TIA for any responses!

No apology needed. If you read back to the types of orders we write you will see it is not much of a risk at all. Cant really hurt someone by putting Calmoseptine on a stage 1, or Nystatin powder on an obvious fungal problem. The doctors know that as well. We dont TO anything PO, PR or Injections... without a real order. To be honest we occasionaly sneak Tylenol for a low temp though without any order, if it is after hours. The MDs come in weekly to check on their patient in person so they actually get to eyball everything we are doing.

There are so many minor things going on all the time that the MDs literaly could not do their jobs without this unofficial system for doing things. Our medical director has at least 100 patients at just my facility. It is like many things going on.

The state inspectors are not stupid and know what is going on. I believe they could probably walk into any facility in any state and find reason to shut it down(at least temporarily) on any given day or find reason to suspend the license of any given nurse if they REALLY wanted to.

Your questions are identical to the ones I had in school but I am now comfortable with answers I have found. If you truly try to do things stricly by the book you wont make it in LTC/SNF, psych and the state knows it. That is why they normally come in with a predetermined list of thing to look for and if you dont get stupid in front of them you will be ok.(if you get stupid you force them to do their job)

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We have standing orders for several meds (MOM, Kaopectate, Tylenol, Robitussin) and as well as trx's not serious wounds mind you. Anything else, I always get always talk to an MD first. Our MD is fantastic, and he trusts our judgement, but at the same time...I respect him. He deserves to know if there is a change in the condition of one of his residents. I work third shift..so if it is very important I will call and wake him. If it is not, I will wait until the am. I don't ever want to be in a situation where I wrote and order the dr didn't know about. One nurse I work with is even worst then I am. She will call and have the time changed on finger sticks if the patient is LOA and is coming back and hour later than his regular fingerstick time. I KNOW he doesn't want to be bothered with this LOL

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