Question on orders in OR

[surgnurse2]

Fairly new to the OR, if a doc wants a foley in the OR, is it ok to be placing if no "orders placed?" Obviously he/she is unable to input these orders but is there any kind of policy that says if when in the OR an RN can do these things with just a verbal since physician is in room? If yes, then to you have the doc go back and input this order later or does it fall under any kind of policy in within surgery? Thanks in advance

[Rose_Queen, BSN, MSN, RN]

Depending on your facility, your policy and protocol may negate the need for a specific order. For example, if we are expecting a surgery to be over 4 hours or the patient has received an epidural, protocol is foley placed unless specifically stated by the surgeon not to place one. Our preference cards also fulfill the role of our standing orders, so that the surgeon doesn't have to place an order for each patient to have local on the field for use prior to the patient entering the OR (also covers certain types of foleys, such as temperature probe foleys for brain and heart surgery). Because we are using an electronic medical record, the surgeon then simply signs off on the medications used during surgery. Additionally, check your P&P for when verbal orders are appropriate. I can't imagine that any place would think a verbal order from a scrubbed surgeon would be inappropriate seeing as the alternative is for the surgeon to break scrub while a patient is in the middle of surgery.

[MereSanity]

I agree. We have basic, understood "standing" orders. Meds are pulled from the preference card as also are foleys placed. We hang fluids off a pump (a big no-no anywhere else), and pull bag after bag of fluids with no order. It's just the nature of the OR.

[ORoxyO]

We are not allowed to cath without an order. If an order is not in, we put the order in and the doc signs it later. If a doctor inserts the foley, we just chart it without an order.

[TraumaORnurse]

We don't have specific orders written in our OR, we do what the surgeon and/anesthesiologist requests or what's on preference cards. They will write orders post-op based on what we've done such as maintaining foley or removing POD#1.