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Putting in orders without an order.

Nurses   (2,549 Views | 42 Replies)

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

965 Profile Views; 28 Posts

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. 

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klone has 14 years experience as a MSN, RN and specializes in Women's Health/OB Leadership.

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Um...no. I guarantee, the minute something goes south, the physician will NOT protect you. And then you will lose your license.

Edited by klone

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Davey Do has 41 years experience and specializes in Psych, CD, HH, Admin, LTC, OR, ER, Med Surge.

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1 hour ago, Kastiara said:

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

Yeah- do it all the time with Docs I know that know me. Never ever any controlled substances or with Docs that I don't know, or big deal things, but standard orders, like admitting orders, that I know they'll approve, I do it.

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7 hours ago, klone said:

I guarantee, the minute something goes south, the physician will NOT protect you.

Nor should they. I can't even imagine dozens of people running around entering orders as if they were given by me.

**

OP, yes I have done it many times I suppose, though usually over stuff that was more protocol than independent decision, and now it almost never comes up because via EMR we can enter those orders as protocol orders (pre-approved orders that can be enacted in certain situations; or preapproved nursing orders for certain situations).

I wouldn't do what you're describing, just set up better habits for yourself. They need to call the providers and if there is some unit-culture reason why they aren't--don't get in that habit. Do things your way (the right way). If you get pushback for calling over things that other nurses don't call for, you can talk to your manager about why you all don't have any protocols. This is one of those things were you definitely don't need to do what your peers are doing and if you are confronted over it (by docs, charge nurse, others) you can just hold your ground.

 

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Tweety has 28 years experience as a BSN, RN and specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

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I don't do the things you describe.  

But for example if someone says "I'm a vegetarian", I don't call the doctor and ask for a vegetarian diet order, I just TORB it.  There are some docs I know very well and sometimes will TORB stuff like a laxative and tell them when I see them.  But nothing beyond simple routine stuff like that.  

The BON shies away from nurses practicing medicine without a license.

Edited by Tweety

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1,193 Posts; 8,026 Profile Views

It depends. We put in a lot of orders ourselves to begin with.  I will often through in a restraint order then when I see the physician next, I say Hey, I put such and such order under you, just do you know when you are signing.

I never put in medication orders without a verbal.  I know nights often puts in routine labs on their own which I don’t see as a big deal.  But on days, I get a verbal first.  But diet, restraints, PT and OT, I do myself. 

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FacultyRN has 13 years experience as a MSN, RN.

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Are they entering standing orders that have been approved for your unit?  Standing orders are appropriate; they are written protocols, signed off by a physician, that allow nurses to order and initiate tasks when indicated.

For example, when I worked as an ER nurse, I could initiate 12 lead ECG, IV placement, cardiac labs, nitroglycerin, aspirin, oxygen, etc. for chest pain patients because my unit had standing orders for that situation.  The physician orders for these tasks already existed in the unit manual, and the nurse would enter the orders in applicable charts and initiate the actions.

Standing orders tend to be specific to chief complaints, symptoms, and assessment data.  They allow the nurse a lot of flexibility and autonomy in handling situations, and the nurse uses clinical judgment to determine if they're appropriate to implement for a given patient.

On the other hand, if nurses in your unit are practicing medicine by writing physician orders willy nilly, that is inappropriate and illegal. 

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AnLe has 2 years experience as a ASN, RN.

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I work night shift. I put in telemetry orders when applicable for one doctor. Stroke, chest pain, seizure, etc. She has stated if a chest pain patient comes in to do one troponin and an EKG. This doctor tends to put in orders rather late. Other than that, I am not comfortable adding or amending any order that I did not hear verbally from a doctor.

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Orion81RN has 7 years experience.

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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.

2 hours ago, AnLe said:

I work night shift. I put in telemetry orders when applicable for one doctor. Stroke, chest pain, seizure, etc. She has stated if a chest pain patient comes in to do one troponin and an EKG. This doctor tends to put in orders rather late. Other than that, I am not comfortable adding or amending any order that I did not hear verbally from a doctor.

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

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421 Posts; 2,023 Profile Views

I had a doc tell me early on in my career (working military) that if we wanted to give a patient something they could buy OTC she'd write an order in the morning (PP/AP/Gyn surgery), but that was 30+ years ago.  I've ordered labs when other labs have already been ordered, just so they don't get stuck again when the doc realizes they need what I ordered.  But nowadays I wouldn't do that because I've learned better through harsh experience (ie; doctors lying).  I wouldn't fool with med orders at all.  Even if you trust the doctor if something goes wrong it might not be her/his decision to throw you under the bus.  Don't risk your license.

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

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IMO: Ordering telemetry orders to continue overnight, adding a No Caffeine order when a test is ordered that requires that stipulation, Standing daily weights; these are different than medications, labs, and restraints. (Look VERY closely at and follow your facilities policies VERY carefully. Following standing order sets are very different than putting in labs and adjusting medications just because that's what you assume the Dr would do.)

 

Definitely think carefully about this, and encourage other or new RNs starting in your area to be very careful about this "practice." Ordering something as "simple" as a laxative on a post-surgical patient may seem appropriate, but depending on the type of surgery or what happened during, that medication may not be appropriate per the Dr and you (or whoever) will have a really difficult time explaining why you were practicing outside of your scope.

It sounds like a potentially dangerous line the other nurses are walking (if they are doing this without standing orders, etc) and setting this example for new RNs is not appropriate or safe.

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

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4 hours ago, FacultyRN said:

Are they entering standing orders that have been approved for your unit?  Standing orders are appropriate; they are written protocols, signed off by a physician, that allow nurses to order and initiate tasks when indicated.

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. 

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