ordered to sign orders for previous 24 hours...for someone else

KimburlyB · Jul 21, 2012

At the start of every shift we look back through all of our orders to verify that they match the MAR and that no labs/ tests ordered were not completed. I have found discrepancies more than once that are days old ( yes, this means some people are skimping on the chart check). If you are signing an order off with the current time and date then it is not illegal. You are not saying you did it when it was written. You are saying I see it now and it was implemented as written.

KelRN215, BSN, RN · Jul 21, 2012

Ok, so say an order is written for "wet to dry dressing changes BID" at 2pm and the day nurse never saw it/never signed it off. I would sign it off when I got in/saw it and the order (in the computer) would read: "Wet to dry dressing changes BID- ordered by Joe Smith, MD on 7/21/12 at 2pm. Nurse reviewed by Kel, RN on 7/21/12 at 7:30pm." I have acknowledged that I saw this order, I agree with it and it will be implemented. That the day nurse did not do it on her shift is not my concern- this is an order that pertains to my patient and involves my time so I review it. It's not illegal to sign off orders with the correct date and time. I would be more concerned about the legality of leaving it for Suzy Brown, RN to sign off on it the next time she works- which may not be for several days. If she's not working until, say, Tuesday is she expected to sign it off and back-date it? She didn't actually sign it off then and the order was not carried out by her/on her shift.

Hay, RN · Jul 21, 2012

Really... if I understand you were required to sign off orders that you didn't take? Easy solution. Just make sure that they were ordered/carried through then you can sign it off. If you see that it hadn't been carried through/done then there's a problem and you need to let the charge nurse know and NOT sign it 'til it's completed.

ShayRN · Jul 21, 2012

The way I am reading it it this, they want her to sign for things she didn't complete. For example, a drug is ordered BID and the 10:00 am dose wasn't given. Her manager wants her to go back and sign for it like it was given, even though she was off that day. If that is what she means, then HECK NO I would not do it. If it is just a matter of transcribing the order, that is different.

dudette10, MSN, RN · Jul 21, 2012

I would not sign for anyone else, especially if I was not in the building at the time the order was initially written.

Other nurses I work with have said the same thing about not signing off. Don't do it, they say. I have never been given a good reason, and I can't think of one myself. Maybe I'm missing something about it that would make me potentially liable.

If there was an order for, let's say, KCL 40 meq po x 1 today written by the doc at noon, and the day shift didn't sign off on it, I would check the MAR to see if it was given. If yes, I would sign off with the current date and time. In that case, I'm just verifying that the order was indeed carried out. If the med wasn't given per the MAR, I would sign off and give the med. If I don't do that, the patient isn't getting what is ordered.

Within 1-2 hours of shift change, some orders are missed. Why would I leave them undone/unsigned just because they were written on the previous shift?

Two scenarios pop up in my mind that are worse than a correctly timed and dated sign off for an oncoming nurse.

1) I am the offgoing nurse. I sign off on orders that I don't have time to implement. The oncoming nurse doesn't do it because I signed them off. (edited)

2) I am the oncoming nurse. The previous nurse signs off on orders she doesn't have time to implement. She forgets to tell me. The patient is not getting what he/she needs because of it.

I work nights and do 24 hour chart checks. When I sign off for the checks, I'm the second sign off that everything had been done in the previous 24 hours. So, in effect, I'm signing off on orders for two shifts that I was not present to receive.

Can someone please provide an example of a correctly dated and timed sign off, even if hours later by another shift's nurse, that influenced a bad outcome, legally or r/t patient care.

netglow, ASN, RN · Jul 21, 2012

1. You are signing something that just states that "some RN" (you) acknowledge receipt of a new order for a certain patient.

-This means only that, the order was received and a qualified person acknowledged it's receipt (like a certified letter, or signing a fed ex - yes it was delivered and arrived OK)

2. You are signing that you have received/acknowledged the order and have completed the action it requires.

-Means just that.

3. You are signing for someone else who may or may not have received/acknowledged the order and completed the action it requires.

-Means that you basically are taking one for the other RN, who the hell knows what she/he did or did not do ...Nobody cares because you signed your initials and that means you are saying that you personally received/acknowledged the order and completed it yourself.

Note the differences here. "Taking down orders" and making them part of the patients EMR is different than actually following and completing what is ordered. Most places, that is two different signatures. If something is to be done on your watch, or is a NOW order, you not only need it to be acknowledged in the EMR, but you need to do it NOW. Other instances are where you see the order, acknowledge it, but it might not need to be completed on your shift.

dudette10, MSN, RN · Jul 21, 2012

Other instances are where you see the order, acknowledge it, but it might not need to be completed on your shift.

I forgot about that type of scenario, which happens relatively frequently: a doc writing an order for a future action, e.g. d/c Foley in am; take PVR with bladder scan and report if >100 ml. Unfortunately, where I work we have only a verbal mechanism for passing the info on, unless the nurse on the shift when it should occur reviews previous shifts orders, like nights w/ 24 hour checks.

hopesgramcracker · Jul 21, 2012

Thank you everyone for your input, all of this is still a learning process for me.

netglow, ASN, RN · Jul 21, 2012

1. You are signing something that just states that "some RN" (you) acknowledge receipt of a new order for a certain patient.

-This means only that, the order was received and a qualified person acknowledged it's receipt (like a certified letter, or signing a fed ex - yes it was delivered and arrived OK)

I'll edit to add that the reason for the formal signed acknowledgement of orders is to state that a qualified person has actually read the order - which is important of course because you, cannot then say, I saw there was an order but didn't know it was urgent or whatever. If the RN before you acknowledged the order at 1400, but someone died and someone fell too, well she's gonna say I acknowledged a few new orders but I got in over my head here and didn't get them done before you arrived at 1500, sorry, but they still need to be done. But, I'd still take a quick look for any new orders/undone orders myself anyway... I just would never sign something as completed unless I did it myself.

Simply Complicated · Jul 22, 2012

I sign orders all the time from the previous shift. Until recently, we worked 8 hour shifts. One of the doctors has a tendency to do his rounds in the early afternoon, so when I came in at 3, there were frequently orders from day shift still. Our MAR is electronic, so you don't note/sign the order off until you can verify pharmacy has entered it into the system. So technically I am signing something that I was not present for. Same thing with labs though. All I am really signing is that Yes I see the order, Yes I verified the medication is on the patients MAR, or Yes, I am verifying the lab is entered into the computer to be drawn at the ordered time.

92GRAD · Jul 22, 2012

Signing off on written orders, written by the M.D.- written by MD not on your shift. IF directed by your Manager to do so; the manager, should not advise you of something "illegal". If questioned about it; you must say, "I was directed by my manager, following the managers direction". I doubt that you'd ever be questioned.

the hospital is wanting all the t's crossed and i's dotted. Just make sure, the order has been actually ORDERED on the computer etc. :) Or if it is an order you need to be aware of for your patient's care on your shift. :)

I have done it, inorder to "help in the need to dot i's and cross the t's".

The hospitals get "surveyed" by various government regulators, it looks "bad" when the ORDERS are not "noted" by an RN. It will send up "RED FLAGS" to the surveyor/chart auditor. That is one the reasons, your manager, requested you and others to do so. "The noting"

indicates, and RN did acknowledge it and was responsible to see that "the orders", were handled correctly. :)

Esme12, ASN, BSN, RN · Jul 22, 2012

You just don't sign them without checking they were done. Most facilities thatI know of perform 24 hour chart checks to ensure all orders were seen and carried out. If you find a set that were not seen and carried out you just carry them out and "take them off" as if they were just written. Time sensitive orders, like "stat" or "in 1 hour" need to be clarified with the MD and the MD needs to be aware that they were not done earlier......an incident report should follow.

The notation of orders is that someone with a license has checked that the orders were in the computer and transcribed.......this is not an indication they were performed or that you performed. It is an indicator that they were viewed by the licensed personnel and that they were transcribed/entered correctly into the computer and MAR. "Notation" of orders means...."Yes I saw them", "Yes, they are in the computer correctly" and "Yes they are on the MAR correctly". You are not signing tha tthey are carried out correctly.

The statement that Joint Commission looks to see if all orders were looked at/noted by the licensed personal somewhere within 24 hours.......the answer is yes they do check.