nurses writing their own orders

Sparrowhawk · Aug 24, 2009

Our facility's doctor has writen out a sheet of TO we can write without calling her..such as treatment orders and the like...might be something like that.

nursenow · Aug 24, 2009

Yea, I dont call to get an order for a late finger stick either. I do know that if we think we need to do a finger stick on a patient we can do it without an order and call it first aid and then tell the MD after the fact. Kind of like giving O2 to a patient as first aid when the patient doesnt have it already listed as a prn. Most of our PRN meds(tylenol, immodium, cough syrup... ) are not indefinate orders and expire unless we get an order to continue them or write our own TO to continue them. In that case the MD will see it when he/she comes in weekly. Sometime they will ask us why but 99.9% of the time they just sign the order.

nursenow · Aug 24, 2009

Our facility's doctor has writen out a sheet of TO we can write without calling her..such as treatment orders and the like...might be something like that.

That sounds like a great idea but I wonder if the MD is sticking their neck out by putting that in the form of a written record? Technicaly we are supposed to get an order each time because the MD is supposed to have done an assesment of some type on the patient before issuing an order. Calling them for an order allows them to do that based on info they recieve from us which covers their behind. They can assume our info is correct, if not it is our behinds. In the end though, I am glad we are able to write absent TOs. Makes our job so much easier.

LockportRN · Aug 24, 2009

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.

Elizabeth, be very careful with this practice! I know that there are nurses that do this BUT if you look at the nurse practice act, you cannot leally do this, unless, there are 'Standing Orders' written by the medical director AND it is written in your Policy and Procedure Manual at the facility where you work.

Also, until you are comfortable with what these standing orders, always call the doctor. Even then, I would make it your practice (I'm sure that you worked hard for it) to at least make a follow up phone call at some point in the day to alert the MD of what you orered (standing orders or not, and whether they get mad at you or not) to alert them of a 'Change in Condition' of HIS patient. This can be done as easily as leaving a message from you (the patients' nurse at the facility) to the MD's office nurse. Then chart that he has been informed. If the md wants to make any changes or call to inquire about the patients conition, he can and you won't be tied up waiting for a return call.

If your DON/DNS will not give you a direct answer it is probably because there are no standing orders and there is no Policy or Procedure written as guidance. This is a liability issue whether the DON/DNS wants to address it or not. If she answers you and there is no policy, she could be held liable, conversly by not answering you directly, she is making you accountable for your own nursing practice. She is probably aware that this occurs and frankly many docs allow this to occur with seasoned nurses that they have an established relationship with...which is crucial.

I have been a DON of 4 SNF's and always make sure that we have written policy's and hold monthly Nurses Meetings to make sure that they know the policy's or here to find them. In any case, you should make sure that your nursing insurance is up to date. Best of luck!

Indy, LPN, LVN · Aug 24, 2009

Standing orders do not hurt the physician if they round in timely fashion. Inpatient hospitals, for example; the docs round daily. So standing orders make sense, so do protocols. For example many drugs have whole order sheets that go with them as a protocol, they cover everything up to a code on the patient, like cardizem, dopamine, etc. Also for insulin management, we have sliding scale orders that also cover D50 for very low sugars, glucogel, glucagon, whatnot. The doc just has to pick which sliding scale to use and what type insulin. It covers "nurse may do fingerstick to check suspected hypoglycemia" so you have extra sticks when you need them.

Many docs leave standing orders, the facility keeps in a book at the desk or in the computer. You use 'em when you need them. They help when you need say, labs for suspected UTI, xray because you reinserted a feeding tube, blood cultures if the temp's over 101, etc. No need to wake doc up for all that stuff. They do standing orders because they want you to use your judgement and get the basics done, period. If you didn't use your judgement they'll be asking you why.

Now as to the thing about doing stuff without a standing order and just writing it yourself: Know the situation and cover your butt. For low blood sugars in the very dangerous range, with the attending being one who doesn't use standing orders, I am covered by ACLS to correct that blood sugar before it becomes a brain damage situation. If I don't think I have time to call the doctor I will correct first and then call. "Hey I did this because the lab took an hour getting my result, and it wasn't time for a fingerstick, but the result was 35 and it was an hour old, she got 1 amp D50 about two minutes ago. Anything else you would like, since (insert explanation of any other factors here)? " In that situation I appreciate being able to talk to the doctor about a LIVE patient and if they don't like it, I can document and pass it on to management. I tend to get aggressive on stuff that will avoid a code if I think it's necessary but it is because I am certified to run the code when it happens.

Also in one facility I worked at you had to notify the doc if you put the pt. in restraints. Well since the need for restraints means you can't be talking on the phone while protecting your safety and tying some wild person up, of course it's a call AFTERwards. And you use that opportunity to explain what's going on with the pt, and ask for sedatives, and ask for a foley. Seriously. If they are wild enough to need 4 point restraints then what do you want them to do, pee at the ceiling? I never had a doc refuse to give the order and/or refuse permission to place the patient in restraints. I don't honestly know what I'd say to someone who said no, untie them. We'll cross that bridge if I ever come to it. Where I am now, you don't call for that. Tie up, put order sheet on chart, keep pt safe and take 'em off when you are able.

With all that crap in mind, make a point to know your doctors and pay attention to your gut. If you have that little voice telling you, maybe you should call before writing a T.O. for whatever it is, and if you have to discuss it with a few other people to justify your writing it, well you should just call. If your charge nurse likes to play the T.O. game and write for stuff you want, and she signs 'em herself and takes responsibility for it, you can opt to let that happen and follow the order. Anytime you write the T.O. and it isn't a T.O., keep in mind that the doc can have a little hissy fit and it can be a license issue if the doc, facility, whomever, decides to report it to the board. It wouldn't ever hurt to suggest standing orders and protocols be put in effect.

Freshman RN · Aug 24, 2009

"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?"

The doctors still have to sign behind you.

Are you sure that there isn't a list of standing orders??

There is in someplaces an "accepted practice" if someone is on a vent, you apply scd's ng, foley get a ua with the placement, wounds get e would culture, PT etc.... And there are "accepted parameters" PT( who writes dressing orders), Respiratory therapy( who changes the vent), pharmacy( who makes or changes dosages) who act and write orders based on their job.

my advise Know your doctors, your hospital and your nurse practice act.

breaktime · Aug 24, 2009

Thanks to all the responses (to the OPs question and to my own). As for standing orders, I'm of standing orders and such. It seemed to be implied in the OP that nurses were writing orders as a TO when in fact they never spoke to the MD. I got the answer to my question through the various posts, and thank you all for the information. Hopefully the OP also came back to this thread to see the advice that was posted.

John20 · Aug 25, 2009

Lots times I've had frustrated doctors say "I don't care what you give them". I end up writing the order and the doc usually signs it without looking. Half of this comes from a trust that we have built with each other but I'd still rather have them give me the order.

LockportRN · Aug 26, 2009

Lots times I've had frustrated doctors say "I don't care what you give them". I end up writing the order and the doc usually signs it without looking. Half of this comes from a trust that we have built with each other but I'd still rather have them give me the order.

Yes, the docs do get frustrated and mostly will sign off on these orders but I have been on the receiving end of an MD's fury when a nurse wrote a TO without making a follow-up call to alert him of this action and update on the paients' condition. In this case, the family did not trust the nurse to fully follow through and called the MD themselves and he of coorifice, was caught off-guard, not knowing anything about the condition change.

I had a physician once give me an order on a new admit that was NPO and had a new GT placement to "just take a can of whatever you have around there and bolus feed them"! He then said goodbye and started to hang up...oh really mr. MD?????? I thought, well, I have a can of diet coke here, will that suffice? A can of OJ??? How about can of oil?! :banghead:

While we as nurses know what to do, again, He was the physician, not me. The patient placed their trust in HIS judgement, not mine. And as they were a medicare patient, the same can be said for the government that pays the MD's salary for His !!!"

For the OP, if you make the decision to write a TO prior to speaking with the MD, at the very least, leave a message with his nurse. This should be followed up by you with him the next time that you see him. Tell him of your actions (in general 'Doc, I know how many phone calls that you get everyday, do u mind if I wrtie TO's for basic care issues, for example, in the case of a skin tear etc. Then just leave a message with your service or your nurse what happened (the patient bumped his hand on the bedrail and sustained a 5mm skin tear and I wrote treatment order per protocol)? Then follow his lead.

Daytonite, BSN, RN · Aug 26, 2009

It depends what they are writing the TOs for. When I worked in LTC there were a lot of little administrative things that we wrote TOs for that had to be in the charts as doctor's orders that the doctors could have cared less about. That said, however, I always sent a fax to the doctors office informing them of what kind of TO I was planning on writing and asking for permission first before actually doing it. The doctor has to actually end up signing those TOs anyway for them to be valid. If they don't, someone in the office tracks the doctor down and hounds him until he signs them. Nurses don't see that part of the process. Then you get cranky doctors. In the chart we had to have orders for the diet and all activities and that generally created some of those funny TO orders. When we reconciled the medication and treatment sheets each month we sometimes found orders so old nobody knew when they were written, who wrote them, or why they were still on the MAR or TAR, so they really needed to be removed or the state surveyors would have a field day with us at the next inspection. Sometimes we would just write TOs to D/C those treatments. Again, I always sent a fax first to back up what I was doing and have a documented record--safer for myself that way. The returned fax with the doctor's signature was put into the chart as well as a nurses note documenting the fax and its return and the writing of the TO.

nursenow · Aug 26, 2009

If we send a fax asking for permission to write a TO that makes it a FO(fax order) If he signs that fax there is no reason to right a TO. You just got his permission via fax. We then write the order into the Physicians orders section of the chart, place the fax into the chart and when he comes in he signs below where we wrote the order.

Nurse2Doc2008 · Aug 30, 2009

So when I was a nurse, I generally didn't do anything w/o a written/verbal order. However, last night on call, I actually had a nurse who ordered a lab under my name on the computer!! I was putting in orders for a new admit, and got stat paged for a patient who was coding down the hall and didn't log out of the computer in the resident work room. While I was gone, the nurse came in, I guess to ask me for the order, and when I wasn't there, she just put it in under my log in!!! I thought this was really unprofessional and dangerous....it was only for a lab that definitely needed to be done, but I still felt it was really, really inappropriate. I told her that in the future, I would prefer she not put in orders under my name, even if we'd spoken about the order (which we hadn't in this case), especially since I was in the hospital at the time. Obviously, I'm the one who is accountable for whatever gets ordered. Oh, and also, I obviously should have logged out, I just was not thinking about it when the code pager went off...