Putting in orders without an order.

LovingLife123 · Feb 9, 2020

6 minutes ago, Kooky Korky said:
why can't docs do their own jobs?

While I agree with this, I also realize that our docs have like 20-25 patients on my unit alone and I have two patients. So I can tell them what I need, and wait for them to finish rounding and maybe get my order 2 hours later, provided they remember and I don’t have to page and remind, or I can say do you mind if I put that in for you?

I’ve been on my unit for close to 7 years. I know my docs and which ones do what. Some renew restraints when they first get in at 0700, others don’t. All of our vented patients get restraint orders. So if they are not renewed and I’m at that 24 hour mark, I put them in.

I absolutely do not put in my own med orders. I only put in meds with a verbal. I do not redo titration parameters on drips. I go to them first and ask if it’s ok.

We recently added NPs and residents to our unit within the past couple of years. It’s been extremely helpful on the orders getting put in and having someone always on hand.

Career Columnist / Author · Feb 9, 2020

Be very careful and know your policies.

Make sure there is a policy for what you believe to be a standing order. For example, you may have a standing order to order a 12 lead EKG if a pt presents with chest pain. In that case, you are covered. But...look it up.

Under CMS, standing orders address well-defined clinical scenarios and must be formally approved by medical staff, nursing (and pharmacy if applicable). Standing orders route to the provider for co-signature.

Consider if you ordered an ABG bc you believe it to be a standing order, when it's not. You have to place the order under a provider's name, so you choose the attending. She refuses to electronically sign the order. The pt develops an abscess and sepsis. In an investigation, the provider will deny ordering the ABG.

Likewise, interventions ordered without a provider can be refused reimbursement by insurance.

Tegridy · Feb 9, 2020

Back when I worked as a hospital NP the icu nurses did this all the time. Especially when I was a new grad the seasoned ones guided me through things are where very helpful. I was greatful that they did this and pretty much all their orders where good choices. I think I’m the whole two years I worked I refused to sign one order bc it was a bunk order that someone probably signed to me by mistake. The novice nurses usually are too afraid to do this with good reason

long story short though I probably wouldn’t do it unless you know the provider very very well.

FolksBtrippin, BSN, RN · Feb 9, 2020

On 2/7/2020 at 12:23 AM, 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.

Are there not standing orders? Some of this stuff seems routine, like labs. If folks think you're being overly cautious about that kind of stuff, they might be right.

Restraints are initiated by the RN and then doc signs the paperwork after doing a face to face... this is the law where I live. So restraints are an always call the doc situation for me. Right away.

When I worked in the hospital, I would make a list of orders I needed and when the doc came around I would grab him and quickly run through the list. Very quickly.

If a doc was a jerk about getting asked for orders I could see why folks might just put them in.

But that's a problem. Because we can't fly solo.

On the other hand, make sure you are willing to take some responsibility. There are things we can and should do without an order. I can't stand nurses who refuse to take any responsibility.

Rnis, BSN, DNP, APRN, NP · Feb 9, 2020

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.

I have seen someone fired and reported for the board for this. She had been a nurse for a long time at the facility. As a prescriber, I am not okay with people putting in an order without my consent and I would not back them up. We have strong standing orders/protocols in place that I sign and support.

Quota, BSN, RN · Feb 9, 2020

The only orders I put in are standing order type things, per protocol stuff. It’s understood and already discussed with our MDs that we can place orders for heparin flushes to de-access mediports when they forgot to put in the order. Restart diets after procedures that required the pt to be NPO. Otherwise I talk to the doctor either in person or over the phone about needing orders. Some enter the orders themselves, others ask us to put them in.

I did have a MD kind of annoyed I called them about modifying a Tylenol order the other week but it was just entered for fever and not pain. Pt had a headache. She was just transferred to me and said they’d been giving her Tylenol for pain. They’ve been on us about checking these orders and not giving if the order isn’t written that way. So yeah, gonna call the MD even if I know they will say it’s okay.

ArmaniX, MSN, APRN · Feb 10, 2020

It is certainly not good practice as you can guarantee, as previously mentioned, if something goes south they will not back you.

When I was working in the ICU as an RN years ago I had a fellow tell me to “do whatever I wanted” in regards to meds/sedation .... at the end of my shift when I saw that fellow I told him “FYI I put bed so&so on a paralytic gtt” ... the look on his face was priceless. (I did not do such a thing).

Kooky Korky, BSN, RN · Feb 10, 2020

23 hours ago, LovingLife123 said:
While I agree with this, I also realize that our docs have like 20-25 patients on my unit alone and I have two patients. So I can tell them what I need, and wait for them to finish rounding and maybe get my order 2 hours later, provided they remember and I don’t have to page and remind, or I can say do you mind if I put that in for you?

I’ve been on my unit for close to 7 years. I know my docs and which ones do what. Some renew restraints when they first get in at 0700, others don’t. All of our vented patients get restraint orders. So if they are not renewed and I’m at that 24 hour mark, I put them in.
I absolutely do not put in my own med orders. I only put in meds with a verbal. I do not redo titration parameters on drips. I go to them first and ask if it’s ok.
We recently added NPs and residents to our unit within the past couple of years. It’s been extremely helpful on the orders getting put in and having someone always on hand.

You are doing it the right way. you are getting verbal orders, which is not what the OP was saying, if I understood her correctly.

It sounded like at her job, nurses were essentially ordering on their own. While capable, it is not legal and if the docs don't agree and won't cosign, that is a problem.

Kooky Korky, BSN, RN · Feb 10, 2020

12 hours ago, FolksBtrippin said:
Are there not standing orders? Some of this stuff seems routine, like labs. If folks think you're being overly cautious about that kind of stuff, they might be right.
Restraints are initiated by the RN and then doc signs the paperwork after doing a face to face... this is the law where I live. So restraints are an always call the doc situation for me. Right away.
When I worked in the hospital, I would make a list of orders I needed and when the doc came around I would grab him and quickly run through the list. Very quickly.
If a doc was a jerk about getting asked for orders I could see why folks might just put them in.
But that's a problem. Because we can't fly solo.
On the other hand, make sure you are willing to take some responsibility. There are things we can and should do without an order. I can't stand nurses who refuse to take any responsibility.

Can you give some examples of nurses not taking any responsibility?

If doc is a jerk, he/she needs to be corrected. Nurses should take responsibility to get said jerk to do his job and be courteous about it. They know that nurses are going to need orders sometimes and they need to behave. The days of catering to prima donas should be over. We save their butts plenty of times and they need to respect us. We do not need to tolerate being in fear of them.

turtlesRcool · Feb 10, 2020

On 2/7/2020 at 7:59 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.

How does your hospital have patients on critical drips, and not have standing orders on titration? Are you sure you're understanding that correctly?

At my facility, I do a lot of Heparin drips, and the titration is written into the order. Since hospital policy is to recheck labs 8 hours later, RNs often order the draws so we can titrate appropriately (which is not something I'm "ordering" in the sense that I'm deciding it should be done; I'm "ordering" only because I'm the person entering the order into the computer so phlebotomy knows when to come). When I change the rate, I go into the MAR and update accordingly (which requires another RN to cosign). I can't imagine a facility where there is no established protocol for titration, even if it's not part of the order set.

Tegridy · Feb 10, 2020

19 minutes ago, turtlesRcool said:
How does your hospital have patients on critical drips, and not have standing orders on titration? Are you sure you're understanding that correctly?
At my facility, I do a lot of Heparin drips, and the titration is written into the order. Since hospital policy is to recheck labs 8 hours later, RNs often order the draws so we can titrate appropriately (which is not something I'm "ordering" in the sense that I'm deciding it should be done; I'm "ordering" only because I'm the person entering the order into the computer so phlebotomy knows when to come). When I change the rate, I go into the MAR and update accordingly (which requires another RN to cosign). I can't imagine a facility where there is no established protocol for titration, even if it's not part of the order set.

Hope they have titration protocols if not that’s a lot of paging and a lot of looking up what to do when lol

Wuzzie · Feb 10, 2020

On 2/9/2020 at 9:14 AM, Nurse Beth said:
Under CMS, standing orders address well-defined clinical scenarios and must be formally approved by medical staff, nursing (and pharmacy if applicable). Standing orders route to the provider for co-signature.

TJC frowns on the term "standing orders" although we have them in EPIC. ?‍♀️ Anyplace I have worked that allowed nurses to initiate orders were by "protocol" and as Beth noted they have to be reviewed and signed by a physician willing to take responsibility. They also need to be updated (yearly?) and have to be re-signed. Trust me, this is a major PITA. In addition they have to be written and kept where they can be viewed. This can be in an EMR system or in a policy/procedure book. That being said when I as in the ED we did not have formal CP protocols but the symbiotic relationship between medicine and nursing was rather well-defined. I would start doing all the stuff (EKG, IV, ASA, Ntg) but the physician was usually either in the room or on the way in and we would sort of verbally agree to do the "normal CP stuff" while passing each other. If we had to wait for the actual orders to be placed patient outcomes may be impacted.