"No New Orders Received" ..... ?

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Specializes in NICU.

When you notify the physician of something regarding your patient and receive no new orders, do you document that?

I can just document: "Notified MD of infant's increased work of breathing. Will continue to monitor."

OR

I can document: "Notified MD of infant's increased work of breathing. No new orders received. Will continue to monitor."

What do you do, and why?

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Specializes in Community, OB, Nursery.

I always document 'no new orders received.' Or whatever action was taken.

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Specializes in ER.

I always chart that physician has been notified and that no new orders received at present time.

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When you notify the physician of something regarding your patient and receive no new orders, do you document that?

I can just document: "Notified MD of infant's increased work of breathing. Will continue to monitor."

OR

I can document: "Notified MD of infant's increased work of breathing. No new orders received. Will continue to monitor."

What do you do, and why?

I always document if no new orders are received. If the baby were to have a bad outcome, I don't leave it open for the doctor in question to argue (read: lie to cover his butt) that he gave a verbal order, and that I must have forgotten to write it in the chart, and have it be my word against his (most of you know how that scenario tends to work out for nurses). Nope, it's already documented right there in my narrative that there were NO new orders.

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Specializes in Community Health, Med-Surg, Home Health.

I would probably say "no new orders" as well. Can't trust those physicians.

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Specializes in Psych, Med/Surg, Home Health, Oncology.

I work with adults; when I notify a Physician, I usually always say " no new orders"; Will continue to moniter or something like that.

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Specializes in NICU.

I always put either "no new orders at this time" or "no change in treatment at this time".

I also put in my note the time I called the doc and the time they actually came to the bedside to assess the pt, if it's more than a few minutes. Last night I had a PCVL going bad, and you can darn well bet that I noted a call to the doc at 2300, and then at 0030 "MD XXX to bedside to assess..."

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Specializes in Emergency.

Bottom line here is CYA.

If I call a doc with an issue, and they do not give me orders I ALWAYS document the issue, the time of the call, the MD I spoke to, and that I received no orders. I also let my TL know what's going on, and that Dr. X was told, and that they did not give any orders.

You are the pts voice. You must be able to document that you did (or tried to do) what was best for your pt no matter what the docs do.

Most docs I work with are great, they listen to us when we call in the dead of night with a concern, and don't get mad that we are interrupting their sleep. They trust us to be their "eyes and ears". Unfortunately there will always be docs with the "God complex", and we lowly nurses who spend more time with their pts don't know what we are doing. So, I always document, orders or no orders.

CYA!!!

Amy

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I wouldn't even think it was a question in today's litigious society; CYA is the name of the game. If I called a physician for anything, I document that I've done so, and why. If I received orders, I document "MD ordered XX med; administered as ordered" or something like that. If the doc said something along the lines of "I'm not giving anything for that" or "I'll be in tomorrow to see the pt, nothing to do now", then I'll document "Notified MD of XXX. MD stated he'd be in to see pt tomorrow, and no new orders were given at this time" or "Notified MD of XXX. MD stated no new orders for this pt at this time".

Absolutely no question of that. Have already had one doctor swear another doctor must have ordered something for one of my patients; my charting showed the date and time I called, the time I was called back, and the outcome of that phone call (and that he ordered zipola). CYA, baby.

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Specializes in NICU.

Well I asked the question, because it is something to question, as I've had someone recently tell me that it's not appropriate, but couldn't give me a good reason why.

If I notify the doctor about something and don't receive any new orders, then I always type in my notes "no new orders received".

I was just curious as to what everyone else does, but by the looks of it, my first assumptions were correct.

Thanks everyone!

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Good for you, RD! There's nothing inappropriate about documenting the outcome of an inquiry placed to a physician. It'd be kinda inappropriate if you typed "stupid MD wouldn't give my pt the antiemitic even though he's about DYING in agony..." LOL.....but if you stick to facts, you're good ;)

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Specializes in oncology, surgical stepdown, ACLS & OCN.
When you notify the physician of something regarding your patient and receive no new orders, do you document that?

I can just document: "Notified MD of infant's increased work of breathing. Will continue to monitor."

OR

I can document: "Notified MD of infant's increased work of breathing. No new orders received. Will continue to monitor."

What do you do, and why?

I always write MD notified, no new orders at this time,will monitor pt. for any change.

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