order

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Specializes in Long Term Facilitly.

I called the doctor to obtain an order for a patient several days ago. When I returned to work, the order was the same however a nurse added to the physician order. Isn't this illegal? I am very worried about this. When I write a verbal order, I don't want anyone to write on same order for it makes it look like I took that order too. I asked her to please write a clarification. No matter how simple the oder, this should not ever be done. Am I correct about feeling this way?

Specializes in telemetry, med-surg and hospice.

Yes you are right. Noone should ever write anything to anyones order. This issue should be addressed with your manager. That nurse should have written a clarification of the order if she had talked to the physician about that order. Good eye. Happy nursing.

Specializes in Day Surgery, Agency, Cath Lab, LTC/Psych.

This is why computerized order entry is such a wonderful tool! No messy handwriting and it is 100% clear WHO placed the order at the specific time. No one can "write over" a computerized entry.

Specializes in onc, M/S, hospice, nursing informatics.

I had a resident do this to me (see my post below). I'd write an incident report to CYA. The nurse should know better.

https://allnurses.com/forums/f8/altering-documentation-210610.html

Once an order is writen by you, nobody should be adding anything to it, no matter how big or small the order. You are then responsible for it. I don't blame you. I would have said something too.

Specializes in Long Term Facilitly.

When I asked the nurse to write a clarification she really was upset with me. Not to mention she is my superior, it really made me nervouse to ask her to do this. I would of not caught it, but the hospital called to ask us to fax the order. She rode my *ss the rest of the day.

When I asked the nurse to write a clarification she really was upset with me. Not to mention she is my superior, it really made me nervouse to ask her to do this. I would of not caught it, but the hospital called to ask us to fax the order. She rode my *ss the rest of the day.

i would have a talk with the next person up the "food chain", this, it would seem, is the beginning of harrassment...best nipped in the bud

Specializes in ER/EHR Trainer.

Never had another nurse add to my orders, but residents were notorious for doing it. Now, after an order is written-I block out the rest of the order page so that no additional orders can be added to the date and time. This way I know when a page is done it is done! You may want to try that.

Maisy;)

Specializes in Med/surg/tele/OR.
Never had another nurse add to my orders, but residents were notorious for doing it. Now, after an order is written-I block out the rest of the order page so that no additional orders can be added to the date and time. This way I know when a page is done it is done! You may want to try that.

Maisy;)

I do the same thing with orders also (blocking it out) I would make a copy of it and show it to my nurse manager. also let her know the other nurse is giving you a hard time about it.:nono:

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