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Putting in orders without an order.

Nurses   (2,522 Views | 42 Replies)

Kastiara has 2 years experience as a ASN, RN and specializes in Critical Care.

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SarHat17 has 8 years experience as a ADN and specializes in CVRU, Intermediate.

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Just now, Kastiara said:

No, not standing orders. My unit doesn't really have many standing orders. They'll put in labs (not routine morning labs) if they think something is off. They'll modify the titration orders on critical drips to match how they went up or down on the drip. Things like that. 

There are quite a few physicians that round on our unit, most of them I have never met in person. Some of them don't seem to mind when a nurse puts in an order under them but others have thrown fits over it. It just makes me really nervous. 

This sounds really unsafe and inappropriate. Ordering ANYTHING invasive (labs, tests, medications) is definitely out of the scope of practice as a RN without the Dr ordering/reviewing first.

Regarding the titration orders: if the order as written is not allowing the medication to be used as the Dr intended (like titrating a cardizem gtt up or down, or even pausing/stopping the gtt per ordered parameters), perhaps the RNs have obtained the clarification from the Dr and are modifying the parameters, etc? That's the only way I can think it's OK. It could be a good conversation to have with the pharmacy/Practice council/ordering Drs about how to change/modify the order instructions. Follow your hospital's policies! Even if the Dr says it's OK to run that med on your floor, if the policy says no, follow that rule. (It's your license and livelihood!!)

I would feel very uncomfortable working with these nurses; I would find it very difficult to trust a thing they say/do! Presumably, you will eventually care for the same patient as they are, either before or after, and you may be the one dealing with the repercussions of their "adjustments and modifications."

Also, the fact that some Drs are NOT on board with RNs doing this would throw a big red flag up for me that this is NOT ok.

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kaylee. has 7 years experience and specializes in Stepdown . Telemetry.

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If a patient appears to aspirate on his diet, i will place npo and get a speech evaL. Sometimes throw in a routine lab if i know the doc will end up doing it at 10. But only with the docs i know and know me. Surgeons, no. I dont put meds in. Except like when they only had tylenol suppository ordered because they were previously npo. I will reorder po. The other one i do routinely is if they get back from procedures i will resume their previous diet. Excluding GI related ones....i use my judgment...

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55 minutes ago, kaylee. said:

If a patient appears to aspirate on his diet, i will place npo and get a speech evaL. Sometimes throw in a routine lab if i know the doc will end up doing it at 10. But only with the docs i know and know me. Surgeons, no. I dont put meds in. Except like when they only had tylenol suppository ordered because they were previously npo. I will reorder po. The other one i do routinely is if they get back from procedures i will resume their previous diet. Excluding GI related ones....i use my judgment...

Agree, I was thinking the same thing. I use judgement and common sense. If a resident is aspirating, I downgrade their diet, no questions asked. 
 

I think a lot depends on the doc

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3 hours ago, Thanksforthedonuts said:

I think a lot depends on the doc

This.

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Caprica6 has 10 years experience.

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I never did...opens you up to much liability. There are nursing interventions that you can use as a stop gap until you can get an official order. If it's a life-threatening event and you need immediate orders, that's why we have rapid-responses and codes. 

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MemphisRN has 43 years experience as a ASN, BSN, MSN and specializes in Hospice.

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Let me think about this. I have 8 years of my life in college and $100,000+ invested in my RN License (ASN, BSN, MSN.) Am I willing to risk my license just because everyone else is doing it? NO!  And I am going to discuss the fact that others are doing it on my unit with my immediate manager. And then I am going to talk to their supervisor if I don't get any satisfaction. I don't even want a hint of inappropriate behavior around me. And I will certainly not do it.

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This is a great topic. Unfortunately, it's very common for supervisors to ignore their staff's working against policy.

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SilverBells has 5 years experience as a BSN and specializes in Rehab/Nurse Manager.

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As a manager, I've put in "orders" that aren't technically doctors orders but are still tasks that need to be done and nurses won't always remember to do them unless they show up on the patients' MAR/TAR.  For example, residents are supposed to have weekly skin checks but unless it is put in as a "task" or "order" to show up on their MAR/TAR they won't get done, especially if the task is overdue.   If we need a consent form for a psychotropic medication signed or a POLST to be obtained, sometimes I'll put them in as "orders" to show up on the MAR to remind nurses that those tasks need to be done.  I have found that simply handing out lists of skin checks that need to be done or paper consent forms doesn't typically ensure that the tasks get done.  With that said, the only medication/treatment orders I will put in without doctor consultation are ones listed in our standing orders.  Even then, I always notify the physician that we have started bowel meds on a certain patient or that a patient is now needing to be bladder scanned and I/O catheterized, etc.   Any new standing order that I initiate, I always follow up with the physician .  As far as labs, our facility doesn't allow nurses to order labs on their own anyway, although we are free to suggest to the physician that a patient may need a urinalysis, etc. 

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8 hours ago, MemphisRN said:

And I am going to discuss the fact that others are doing it on my unit with my immediate manager. And then I am going to talk to their supervisor if I don't get any satisfaction. I don't even want a hint of inappropriate behavior around me.

Is the above related to concern about what will happen if you knew but didn't report or concern that their behavior will put your license in jeopardy, or moral obligation or ?

Just curious.

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On 2/7/2020 at 5:16 PM, Orion81RN said:

I've entered them and put it in a que until the md calls. Then I'd save the orders and it is sent to pharmacy.

That basically sounds like a standing order. So that sounds ok 

except that it is not written or co-signed by doc

On 2/6/2020 at 11:23 PM, Kastiara said:

Do you ever or have you ever put in orders without actually getting an order from the doctor? 

The other nurses on my unit do it all the time. Lab orders, restraints, modifying medication orders, and I've seen some even put in medication orders. I can't bring myself to do it, mainly because I'm worried it will land me trouble both at work and with the BON. The other nurses say I'm too cautious. 

never

when you go to Court, you will go all by yourself, no peers or doc to help you

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23 hours ago, kaylee. said:

If a patient appears to aspirate on his diet, i will place npo and get a speech evaL. Sometimes throw in a routine lab if i know the doc will end up doing it at 10. But only with the docs i know and know me. Surgeons, no. I dont put meds in. Except like when they only had tylenol suppository ordered because they were previously npo. I will reorder po. The other one i do routinely is if they get back from procedures i will resume their previous diet. Excluding GI related ones....i use my judgment...

why can't docs do their own jobs?

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On 2/7/2020 at 6:59 PM, Kastiara said:

No, not standing orders. My unit doesn't really have many standing orders. They'll put in labs (not routine morning labs) if they think something is off. They'll modify the titration orders on critical drips to match how they went up or down on the drip. Things like that. 

There are quite a few physicians that round on our unit, most of them I have never met in person. Some of them don't seem to mind when a nurse puts in an order under them but others have thrown fits over it. It just makes me really nervous. 

don't do it

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