Orders

[Matt]

Hey current and future nurses! I have to admit I'm still a bit confused by how orders work in a hospital. I notice that sometimes nurses on the floor put in orders, but then the next second that same nurse is saying they can't do something because the doctor has not put in an order yet. Then there are things called standing orders.....can someone please explain to me the whole order thing? It seems like nurses will even put in orders, ones that have yet to be signed by the doctor, and in the meantime already execute that order....even though it isn't signed....I'm so confused! Please help. I haven't met someone who could explain this clearly.

[Nurse SMS, MSN, RN]

Nurses cannot write orders. They can take orders from physicians or advanced practice providers (PA or NP) and can enter those in on behalf of the provider. Orders can come written, verbal (face to face) or by telephone. They also can be placed by the provider his/herself. It is not best practice for a nurse to enter in provider orders, as it increases the odds of an error being made and the patient coming to harm.

If you see a nurse entering in orders, then the nurse has taken those orders from a physician in one of the above forms. They also can act on those orders even if the provider has not yet formally "signed" them, because they received the order from the provider already.

Standing orders/order sets are orders put in place for a given doctor's patient(s) with specific conditions. As an example, a physician who regularly performs hysterectomies may have standing orders filed in the facility that they do those at with actions required by nursing for all of their patients who had a hysterectomy. They can include things like wound care, ambulation, pain control, nausea control, when to take out a Foley and the like. These are put in as a set of orders that the physician signs later when rounding. When you get to know the physicians you work with you generally also get to know their order sets or standing orders.

Hope this helps.

[JKL33]

In addition to the above info, I'm guessing at least some of what you are seeing is initiation of protocol orders by RNs.

Protocol orders are those pre-determined and pre-approved (by the physician and nursing leadership in a department/area) sets of orders that may be initiated by the RN in specific situations.

Protocol orders may be initiated by nursing when the pre-defined condition(s) is/are met. For example: A patient comes into the ED with urinary frequency, urgency, burning. The RN will initiate a protocol order for a urinalysis, obtain the sample and send it to lab even if the patient hasn't been examined by physician yet.

Protocol orders may be groups of orders as well; here is one example from a quick google search: https://www.utoledo.edu/policies/utmc/nursing/guidelines/emergency/pdfs/emergency_department_protocols_ed_guidelines.pdf