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

[RainDreamer]

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?

[RainDreamer, BSN, RN]

I've heard that reasoning as well, but I don't buy it. I don't call docs just to chit-chat. The fact that I called implies that I think there should have been orders. Charting that none were received just provides documentation of what happened at that time.

I don't always expect orders when I notify a doctor about something. Sometimes I just think they need to be aware of things. If I have a kid that's spit up a couple of times, but not a large amount, then I notify the doc. I don't necessarily think they need to order a KUB or whatever, I just think they need to know for future reference in case it continues.

If it's something that I think needs intervention and they're twiddling their thumbs about it or they don't want to get outta bed, then you bet I document it and bug the supervisor until something is done.

[elizabells, BSN, RN]

One of the lovely things about computer charting is that you can edit your narrative note. So if I put in "no new orders" and then the doc decides to come out of the call room and take a look, and I end up with orders, I can just utilize the backspace key. Or if I call the resident and don't get orders, and I chart that, and then say I consult with another nurse and we decide that I really NEED orders, I can call the fellow. At that point I usually take out the "no new orders" bit. I've gotten what I needed, and don't necessarily see the point in throwing the resident under the bus. Unless they were a jerk about it.

Kidding! I'm not that mean.

[RainDreamer, BSN, RN]

One of the lovely things about computer charting is that you can edit your narrative note. So if I put in "no new orders" and then the doc decides to come out of the call room and take a look, and I end up with orders, I can just utilize the backspace key. Or if I call the resident and don't get orders, and I chart that, and then say I consult with another nurse and we decide that I really NEED orders, I can call the fellow. At that point I usually take out the "no new orders" bit. I've gotten what I needed, and don't necessarily see the point in throwing the resident under the bus. Unless they were a jerk about it.

Kidding! I'm not that mean.

LOL!

Yeah we have the same type of computer charting where we can edit the notes.

If I wrote everything that every resident says .... that'd sure get interesting because I hear some odd/funny/weird things sometimes!

[AliRae]

The fact that I called implies that I think there should have been orders. Charting that none were received just provides documentation of what happened at that time.

Agreed, but then what did you do about it? If you knew something should be done and you called the doc and hit a brick wall, why didn't you go above that doc to get the orders you needed?

I've been caring for a complex patient the last couple weeks whose uncle is a medical malpractice lawyer ... charting is kind of my soapbox at the moment. :uhoh21:

However, like I said, I'm of the ilk that actually does chart the "no orders received" bit. Just not in the last 2 weeks or so.

[elizabells, BSN, RN]

What if you can't? What if the fellow won't listen to you? Or the attending? I'm not challenging, so much, I'm really asking.

[cardiacRN2006, ADN, RN]

I don't buy it.

I tell the Dr. If he/she chooses to do nothing then it's their fault. I document what I told them, and if it's something important-then I document their response """In quotes""".

But I work in a teaching hospital. So I will just tell the next Dr who happens by....

[RainDreamer, BSN, RN]

I'm with Eliza, what if you do everything you can do?

Actually that's only happened to me once and it was pretty bad. Had a kid that was requiring more FiO2, increased retractions, not acting like himself, etc .... in the intermediate care nursery. The NNP just kept telling me "increase liter flow", blah blah blah .... not really listening. All I really wanted was a gas because I knew it would be bad. I kept pestering and the charge kept pestering ...... finally got the kid moved back into the unit and he coded literally not 20 minutes after being transferred. Next day he's on HFOV, nitric, drips, etc. Eh, she listens to me now! Kinda sucks you have to prove yourself to these people.

I know we're patient advocates, but what if you do everything you can ..... will they still come after YOU? We can't write orders, we can't make the decisions. We can chart all the times we've notified them, we can chart that we've gone to the supervisor, we can chart we went to multiple people. But if nothing is done, is it still put on the nurse? If it is, then we need to be able to write the damn orders!

[cardiacRN2006, ADN, RN]

When I've fought and fought-and it looks like I'm not going to get what I want-I say this (and I really feel that the pt is in distress)

"So, just so I can document this correctly-you are OK with the pt doing X and with his VS being X, and you don't want to do X?"

[elizabells, BSN, RN]

I know we're patient advocates, but what if you do everything you can ..... will they still come after YOU? We can't write orders, we can't make the decisions. We can chart all the times we've notified them, we can chart that we've gone to the supervisor, we can chart we went to multiple people. But if nothing is done, is it still put on the nurse? If it is, then we need to be able to write the damn orders!

:yelclap:

And the answer, Rain, is YES. If you didn't chart that you did your due diligence and that the doctor made a CHOICE not to act, the hospital can (and may) throw your ass under the bus so fast you can't blink. Unless you're one of the favored, in which case the doctor probably would have listened to you in the first place and you wouldn't be having this problem. At least that's how I perceive my unit to be. Your mileage may vary.

And you can damn well bet that the time I had a kid on ECMO start pouring black fluid from her replogle tube and the intern told me (condescendingly, I might add) that gastric secretions sometimes turn black as they pass through the colon (and back out the replogle... how, exactly?) that I quoted her directly in my note.

[AliRae]

We can chart all the times we've notified them, we can chart that we've gone to the supervisor, we can chart we went to multiple people.

I guess this is the important bit. If its just "no orders" and you give up, then there's a bit of a problem. But if your notes are showing that you DID go down different avenues and DID try all your angles, then it's a perfectly acceptable thing to chart.

I work in a teaching hospital, too, so my 'no orders' notes are usually followed within a few minutes by a note about the NP, fellow or attending I spoke with in the next office over.

[RainDreamer, BSN, RN]

:yelclap:

And the answer, Rain, is YES. If you didn't chart that you did your due diligence and that the doctor made a CHOICE not to act, the hospital can (and may) throw your ass under the bus so fast you can't blink. Unless you're one of the favored, in which case the doctor probably would have listened to you in the first place and you wouldn't be having this problem. At least that's how I perceive my unit to be. Your mileage may vary.

And you can damn well bet that the time I had a kid on ECMO start pouring black fluid from her replogle tube and the intern told me (condescendingly, I might add) that gastric secretions sometimes turn black as they pass through the colon (and back out the replogle... how, exactly?) that I quoted her directly in my note.

But if you DO chart that you diligently contacted the docs, supervisors, etc, then you're covering yourself. Right? They'd have a hard time pinning it on you for not advocating for the patient, I would think. But who knows!

Black secretions in the repogle is sometimes normal? Oh that's a new one. Like the time my kid's arm blanched (and I mean the WHOLE entire arm turned white) when I flushed the PAL ..... and the resident told me "that's how you know it's working". Ummmmmmm ......

[RN4NICU, LPN, LVN]

Agreed, but then what did you do about it? If you knew something should be done and you called the doc and hit a brick wall, why didn't you go above that doc to get the orders you needed?

I've been caring for a complex patient the last couple weeks whose uncle is a medical malpractice lawyer ... charting is kind of my soapbox at the moment. :uhoh21:

However, like I said, I'm of the ilk that actually does chart the "no orders received" bit. Just not in the last 2 weeks or so.

Where did I say that I didn't? If I need to go up the chain, I will - and I will document that as well. However, charting no orders received from the first call begins the timeline of occurrences. It is also clear, documented rationale for going over the attending's head.