Patient Orders...help!

[smcelroy5, BSN, RN]

Hi All. I have exclusively worked in the hospital setting my entire career (12 years). I am transitioning to a county mental health clinic so I can get experience prior to beginning my mental health NP.

There is a BIG difference in what is considered appropriate and I am mostly being advised/supervised by non-medical professionals. I have been told to use the MD Progress Note as an order (meds, labs, tox screens), which presents some concerns/questions. I would never use a MD note as an order in the hospital, but I am being told that "we have never had anyone have a problem with this before."

I have also been told that I do not need to have verbal orders signed by a provider??? The rationale is mostly that this is not a hospital, but as far as I am concerned I am a RN no matter where I go and scope of practice is the same. Verbal orders are definitely a thing of the past in the hospital, but I am trying to explain this to people who aren't nurses. Am I being overly fastidious? I have been known to be a black and white thinker, so I'd love some input!

[canoehead, BSN, RN]

Verbal orders need to be cosigned, or in years to come the physician won't know if they ordered it, or you made it up. It protects you AND your employer. I'd hate to peer through a progress note looking for actionable notes, they are impossible to translate at times. Docs need to leave specific orders so there is no debate about what is needed.