Proper MD orders

[quickkarma, BSN]

I am interested in learning if other organizations operate this way.

Nurses where I work are expected to read the notes that MDs write and then go about getting orders entered properly. 

This often happens in the organization where I work. An MD writes the plan at the end of their note; but does not follow through with any orders to carry out that plan. Nurses then will read the notes, and have to decipher how to go about the plan. Often several hours later (when the next nurse comes on and has a minute to read the note), they see that "xyz" is in the plan. Again this is often never placed in any of the "orders." 

Examples are: Plan: stop dilt and switch to oral; stop BB and switch to X. RHC tomorrow. Angio tomorrow. Maintain electrolytes above x. 

As you can see, these are orders nurses cannot enter outside of say, the standard protocol orders. But I'm not referring to any orders nurse have the scope of practice to enter.

Some MDs are worse than others. And some ALWAYS enter their orders that correlate with their plan. 

There are times when we hit the floor running and we don't read notes until 4 hours into the shift. 

Please be honest in your responses. I'm also curious if something happened, does a provider's note hold any weight in that the nurse is responsible if a med wasn't stopped, held, ect., when there are no actual orders. 

Thank you!!

[Kyrshamarks, BSN, RN]

An MD Progress note is NOT an order. If the doc wants it ordered anywhere in the last 10 years  (except ER,that's a different beast) they have to enter the orders.  They all have computer access and training on the computers and know how to enter orders.

[JKL33]

Agree with above. 
 

You mentioned being expected to decipher and go about getting orders entered. Is this expectation coming through nursing channels, medicine/surgery or both? 
 

Have the nurses discussed/reported this through your nursing chain of command? 
 

If you come across a problematic note, page the service involved and say something like "someone on your service wrote a progress note indicating there were to be changes to the plan of care. If that's correct we need the orders entered please.” If they want to give a bunch of phone orders refer them to your institutions policy on that; hopefully you have one that indicates TO/VO only for emergencies (or similar). 

 

[quickkarma, BSN]

Thanks for replies.

This sort of thing happens every day. It has been brought up to nursing management. They expect us to read notes and follow through by, basically doing the MD's job. And on evenings or nights, we then page the hospitalist and tell them... neph/cards/pulm/etc note says this but there are no orders in for it. Nurses are expected to read provider notes and make sure orders correspond to what she/he has written in their note. HERE IS HOW IT IS HANDLED: 1) Some nurses just place the order, literally. ? Again, I am not talking VO/TO. I'm referring to the note. 2) Some nurses will page it out and tell the hospitalist what they need according to what they read. This is what I do and I note it with an FYI. And 3) my favorite... some nurses are like, "This is ***ing bull-***. I don't have time to read notes and hold your ***ing hand. Order your own damn ***." ?

It's truly ***ed up. But this is the honest truth. I am sorry for my language. I keep telling my co-workers that this isn't normal and that other healthcare systems, the providers place their orders according to their notes/plan. I come onto my shift all the time and read a note and see that xyz was never done because it was never ordered. Sometimes I'll ask the previous nurse and they say, "Oh yeah, I didn't have time to read notes." Totally legit response, really. 

When something goes down. I will not have nursing management's back. This I know. But does it hold up in court....the providers note said this and why didn't you question it? Well because I never read it, because I had no time to read it. 

[quickkarma, BSN]

JKL33 said:

Agree with above. 
 

You mentioned being expected to decipher and go about getting orders entered. Is this expectation coming through nursing channels, medicine/surgery or both? 
 

Have the nurses discussed/reported this through your nursing chain of command? 
 

If you come across a problematic note, page the service involved and say something like "someone on your service wrote a progress note indicating there were to be changes to the plan of care. If that's correct we need the orders entered please.” If they want to give a bunch of phone orders refer them to your institutions policy on that; hopefully you have one that indicates TO/VO only for emergencies (or similar). 

REPLY: It is coming through nursing management/nurse educator. And I've tried to tell them this isn't acceptable. We cannot spend our time reading notes and getting things ordered by paging it out and notifying the hospitalist every evening for every patient. Day shift often misses this note-to-order mis-alignment. 

And yes, I page things out frequently related to this situation. It is just ongoing...everyday. 

I imagine the NOC hospitalists are annoyed with this on-going state of affairs operation. 

[JKL33]

That is definitely messed up and it isn't going to get better any time soon with the way it is being handled by management; well and really some of the nurses too. There is no way I would comb through every note and generate orders based on what it seems like they are thinking of doing. There isn't enough time/staffing even if it were a legit way to go about things.  I can hardly believe this hasn't backfired on anyone yet--that no indignant providers have changed their tune said, "that's just what we were considering doing!! It wasn't meant to be ordered, that's why we didn't order it!! Nurses aren't supposed to be ordering things!!"

- Would avoid talking about this issue in terms of time ("we don't have time to read all the notes"); that implies that it is something you should be doing if only you had better time management.

- Would also avoid talking about it in terms of so-and-so RN "missed" something in the notes. That mechanism is not how orders are meant to be generated and we all know it. So be careful not to talk in terms of missing things.

Would only talk about it in terms of it being a safety issue for both patients and nurses: 1. Delays in care (they may listen to this since getting patients ready for discharge in a timely manner increases their bottom line) and 2) There will be no good defense for an RN who misinterprets something and enters an order that was not intended by the medical staff, or enters an order that may have been intended by the medical staff but then did not have a good outcome.

On very rare occasion in my bedside career I took a hard line against something like, "I won't be doing that, it's literally against the law." In my opinion your scenario is one where I would consider doing similar.

I cannot imagine why a prudent RN would go along with this. My guess is that it makes some RNs feel good to be a big shot and independently enter orders.

[LibraSunCNM, BSN, MSN, CNM]

JKL33 said:

That is definitely messed up and it isn't going to get better any time soon with the way it is being handled by management; well and really some of the nurses too. There is no way I would comb through every note and generate orders based on what it seems like they are thinking of doing. There isn't enough time/staffing even if it were a legit way to go about things.  I can hardly believe this hasn't backfired on anyone yet--that no indignant providers have changed their tune said, "that's just what we were considering doing!! It wasn't meant to be ordered, that's why we didn't order it!! Nurses aren't supposed to be ordering things!!"

- Would avoid talking about this issue in terms of time ("we don't have time to read all the notes"); that implies that it is something you should be doing if only you had better time management.

- Would also avoid talking about it in terms of so-and-so RN "missed" something in the notes. That mechanism is not how orders are meant to be generated and we all know it. So be careful not to talk in terms of missing things.

Would only talk about it in terms of it being a safety issue for both patients and nurses: 1. Delays in care (they may listen to this since getting patients ready for discharge in a timely manner increases their bottom line) and 2) There will be no good defense for an RN who misinterprets something and enters an order that was not intended by the medical staff, or enters an order that may have been intended by the medical staff but then did not have a good outcome.

On very rare occasion in my bedside career I took a hard line against something like, "I won't be doing that, it's literally against the law." In my opinion your scenario is one where I would consider doing similar.

I cannot imagine why a prudent RN would go along with this. My guess is that it makes some RNs feel good to be a big shot and independently enter orders.

All of this!  My mind is blown that your institution operates like this, but at the same time I've witnessed enough different unit/hospital "cultures" to believe it's possible.  The bottom line is they're asking you to practice in a way that is blatantly illegal.  You have to decide if it's likely to change, and/or worth it to you to continue.

[quickkarma, BSN]

Thank you for the replies. I agree with it all. 

[Been there,done that, ASN, RN]

Of course it's not legal to write doctor's orders... you are not a doctor. How could the nurse assess the proper dose when switching RX from IV to oral? I would flat out refuse. Each and every time, notify the offending physician. Tell them they need to enter a freaking order! Then chart physician notified for further orders. That issue would be enough to get me outta there.

[canoehead, BSN, RN]

I suggest describing the practice to your board of nursing and getting the official interpretation as to it being legal or illegal, and passing that information to nursing administration, and your colleagues.

[Crystal-Wings, LVN]

I loathe when they do this. It's so irritating. And then they get mad when you don't carry out the order. Well, a progress note is NOT an order. There is a huge difference.