Order Clarification

zambezi, BSN, RN · Jun 30, 2005

It is not allowed at our hospital to transfer with "the same orders" either. For our cardiac surgery patients that are going the the floor we have a set of preprinted orders (about 2 pages long) with the standard meds and some bland lines...the surgeons just cross of what they don't want and write in what they do. The orders have all of the standard prn meds on there too as well as treatments/activity levels/standards of care/labs/cxrs etc on them.

For our non surgery patients (ie: s/p MI, interventional patients) that end up in the unit, we can print off a set of transer orders from the pharmacy...the front page has VS times, a space to write lab orders and activity levels and a preprinted list of meds the patient is currently on (as well as prns). The doctor is to go through and cross off the meds they want to dc (and we cross off the ones they can't use on the floor-versed/propofol if they were vented, etc)...again there is a space to write in new meds and orders on the front. It has been a battle to get our physicians used to these orders and not write transfer with the previous orders...but I think that they are finally used to it!

As for verbal orders, we can take them over the phone and the doc signs them off in the morning. If they are in the unit I will try to bring it to their attention while they are writing orders but if they are doing orders for another patient and it is a minor thing ( like starting out RN driven sliding scale insulin protocol...) I will ask and write a verbal order-which is signed later by the doc.I haven't heard where is is not acceptable to take verbal orders, I wouldn't take a whole page full just because the chance of misintrepreting it is too high...and certainly if the doc is in the unit I will try and have them write what I need...

Just out of curiosity- do you mean that you don't take phone verbal orders of orders when the doc is in the unit and just being lazy??

I hope that you find the answers that you need.

begalli · Jun 30, 2005

I have just started an assignment at a small hospital.
I do not take verbal orders from the physician. I will get them the chart and have them write it or ask them to tell one of the staff nurses.

Are you a traveler? Travelers usually work under the same policy and procedure as staff.

New transfer orders must be written for our patients. We can't make the transfer until they're written. We do not take verbal orders for transfer, the docs enter them in the hospital's computerized order entry system (which the ICU's do not use - yet :uhoh21: ).

As far as I know taking verbal orders is very legal and part of what we do. But some places may have policy on this. Our critical care areas are the only places in the hospital that use order sheets/written orders. We will be going to computerized order entry soon. As staff nurses we are informed that we should try not to take a verbal order (unless in the case of an emergency) but instead encourage the doc to enter the order from where they are - either on the unit or somewhere else within the hospital - where there's abundant access to the order entry system. We will try to train the docs to do it themselves. Kind of like Pavlov's dogs with repetition! :chuckle

Presently, our ICU docs give A LOT of verbals. The rationale for encouraging them to do it themselves is that once we change over to the computerized order entry for the ICU's, it will take time away from a nurses shift to enter the verbal orders. And it will. Handwriting orders is quick and simple. The computerized entry system takes way more time however, for the docs it's nice as far as signing their verbals goes. Each time they log on they are notified and taken to their verbals to sign.

This is the 2nd time in 3 years that the ICU's are trying to get up to speed with the rest of the hospital on order entry. The first time failed miserably. We, the docs and nurses, found that things change so fast and different Residents will write completely different orders within a short period of time for the same patient (especially Medical ICU docs!!) making it necessary to sit in front of a computer entering orders for a good amount of time!

Change is difficult, people are resistant and, no doubt, there will be many many quirks to work out, but this HAS to work this time.

The docs are aware that nursing will be requesting that they enter their own orders and we all are dreading the day, but realize it's a necessary evil.

I also get an order sheet for a doc if they are right there talking about what we will do. I wouldn't worry about taking verbal orders though as long as the doc is qualified to give the order and you write RBVO/RBTO (or something similar), unless your hospital has a policy against it.

hollyster · Jun 30, 2005

It is not allowed at our hospital to transfer with "the same orders" either. For our cardiac surgery patients that are going the the floor we have a set of preprinted orders (about 2 pages long) with the standard meds and some bland lines...the surgeons just cross of what they don't want and write in what they do. The orders have all of the standard prn meds on there too as well as treatments/activity levels/standards of care/labs/cxrs etc on them.
For our non surgery patients (ie: s/p MI, interventional patients) that end up in the unit, we can print off a set of transer orders from the pharmacy...the front page has VS times, a space to write lab orders and activity levels and a preprinted list of meds the patient is currently on (as well as prns). The doctor is to go through and cross off the meds they want to dc (and we cross off the ones they can't use on the floor-versed/propofol if they were vented, etc)...again there is a space to write in new meds and orders on the front. It has been a battle to get our physicians used to these orders and not write transfer with the previous orders...but I think that they are finally used to it!
As for verbal orders, we can take them over the phone and the doc signs them off in the morning. If they are in the unit I will try to bring it to their attention while they are writing orders but if they are doing orders for another patient and it is a minor thing ( like starting out RN driven sliding scale insulin protocol...) I will ask and write a verbal order-which is signed later by the doc.I haven't heard where is is not acceptable to take verbal orders, I wouldn't take a whole page full just because the chance of misintrepreting it is too high...and certainly if the doc is in the unit I will try and have them write what I need...
Just out of curiosity- do you mean that you don't take phone verbal orders of orders when the doc is in the unit and just being lazy??
I hope that you find the answers that you need.

This is how we did it as well.

candyndel · Jun 30, 2005

Those are called blanket orders and are not allowed in our hospital either.

Same thing applies with the blanket post-op order ("Resume all pre op meds")...

We also do not accept non-urgent verbal orders. Its in our policy and is part of one of our PI projects due to a med error that resulted in a sentinel event.

Here's an article that describes the JCAHO 2004 medication safety goals and that blanket reinstatement of medications is not acceptable.....

http://www.medscape.com/content/2004/00/48/23/482368/482368_tab.html

I have just started an assignment at a small hospital. The ICU/CCU staff accepts an order from the physician to "transfer patient to Tele/DOU unit with same orders". Now I have been informed this is an inappropriate order. That the physician needs to write all the orders that they want continued once a patient is transferred out of a unit. What has been the experience of other nurses on this forum? I refuse to rewrite the orders and would like to find out if anyone knows where I can find some legal documentation to use to back up my position.
Also the same ICU/CCU unit takes a lot of verbal orders. I was informed that the only time it is acceptable to take verbal orders is in a crisis situation or verbal orders over the phone. I do not take verbal orders from the physician. I will get them the chart and have them write it or ask them to tell one of the staff nurses. I would like some legal information on this also.
I know the answer for both of these questions, but would like to have something in writing from an official organization to back me up.
Thanks for your time in advance.
Walter

Nurse Ratched, RN · Jun 30, 2005

At our facility, pts can be transferred within the hospital with same orders, EXCEPT when transferring to psych. "Transfers" to psych are actually treated as a discharge/readmission even tho the pt is merely rolled from one floor to the next with no lapse in care. Something to do with funding. The only exception on that case is pt's on Medicaid who are being treated for substance abuse issues. It's all about reimbursement for us.

Sometimes physicians try to just write "transfer to psych." I always make sure the nurses on the floor from whom the pt is being received know that the doc needs to treat it as a new admission. I have had on occasion had to stick a chart in front of a doc and remind him of this (politely, of course :).)

And verbal orders are strongly discouraged here as well - JCAHO no-no.

PJMommy · Jul 1, 2005

Our docs can transfer with "resume previous orders" to lower acuity units. When transferring from low acuity (i.e. med/surg) to high acuity (ICU), they have to re-write ALL orders. Same goes for post-op pt's -- they can't say "return to ICU, resume previous orders"....they have to re-write everything.

As far as verbal orders go -- I take them all the time. However, if doc is just standing at nurses station and gives a verbal order, I say "the chart is right here, write it and I'll do it". I think some of it goes to trust -- there are some docs I absolutely will not take a verbal order from....maybe they are an a**h***, maybe they have tried to burn nurses in the past...whatever. I consider taking verbal orders a courtesy only as the ultimate responsibility for giving/writing orders is the doc's.

ladybug5982RN · Jul 13, 2005

at the hospital i work we are not allowed to take blanket orders.we have a pharmacy transfer sheet that the md must check what meds he wants to stop or cont and he/she must write out all orders that they wish to continue,we have called before and got telephone orders but there must be some kind of written out orders.with our open heart patient we have preprinted post cabg orders.as far as taking verbal orders with the md in front of you our hospital frown upon this,the md's must not be aware of it however because they tell us things all the time with the chart in hand and when they walk away and i check the chart they have not written a word they just said.this makes me very upset :angryfire .on our telephone orders we have to document that we have done a read back and verified with writing r/v after all of these orders.this is per jacho.you need to ask other people at your hospital,i bet they are the same.call the md and get orders and let them know that cont orders is not good enough per hospital policy.if it continues to be a problem i would let my manager know that this md continues to do this.

i have just started an assignment at a small hospital. the icu/ccu staff accepts an order from the physician to "transfer patient to tele/dou unit with same orders". now i have been informed this is an inappropriate order. that the physician needs to write all the orders that they want continued once a patient is transferred out of a unit. what has been the experience of other nurses on this forum? i refuse to rewrite the orders and would like to find out if anyone knows where i can find some legal documentation to use to back up my position.
also the same icu/ccu unit takes a lot of verbal orders. i was informed that the only time it is acceptable to take verbal orders is in a crisis situation or verbal orders over the phone. i do not take verbal orders from the physician. i will get them the chart and have them write it or ask them to tell one of the staff nurses. i would like some legal information on this also.
i know the answer for both of these questions, but would like to have something in writing from an official organization to back me up.
thanks for your time in advance.
walter