Standing orders (Please explain)

Posted

Specializes in Med-surg.

I have been a RN for about 5 months now and still have the feeling I am not getting the answer I want (so like always I need to ask!). We have hospitalists and not residents (I guess thats what they are called). I am really not familiar with the term "residents" because we don't have those at our hospital. (So if someone can key me in as to what "residents" do that would be awesome; I do love to gain knowledge :clown:)

Anyways the "hospitalists" have standing orders for certain things, does this mean I can just take it without calling them and sign off "telephone order dr......." Since they won't want to be called for tylenol at 4 am? Now I have not been doing this because in nursing school we were always told to call the dr before administering something, but is a standing order different. I had one hospitalist tell me "don't call me, just give the order of novolog if they are on it".....now my license is on the line, and I want to protect my license and my butt!!! That is why I am asking you guys for your advice. I asked my manager and he really didn't help me out. I have seen other nurses just sign it off "telephone order dr....." without calling, but when it comes down to it, I am a very honest person and can't lie about anything. Help!!!!

So please tell me experience nurses what would you do?

mentalhealthRN

433 Posts

First of all Residents are in the residency portion of their training. When docs finish medical school they they have 1 year as an intern I believe then their residency--which varies in length depending on their specialty (general med, surgery, peds, psych, etc.) when they finish that residency they become an attending MD. Hospitalists are actually employees of the hospital--attending MDs--who do not have a private practice generally. In a hospital without them they use attendings who both have a private practice as well as see patients in the hospital. Its sort of complicated--and is a little different in each hospital.

If I were you I would ask the docs when they seem like they have some time and are not in a hurry. As far as standing orders. These are already active orders. Usually when a pt is admitted the standard standing orders that should be pre-printed are reviewed and the admitting doc reviews and signs for all at one time-- in case there is anything they want to take off due to allergies, interactions with other meds, etc. Of course things should be brought to the docs attention by nurses if it is noticed that the orders are signed as is and they missed something like crossing off med that the pt has an allergy to.

So no if you have APAP as a standing order for all your pts unless an allergy or contraindicated by disease no don't call a doc for the order--that is the point.

If your docs are not routinly reviewing the list of standard standing meds for each pt (which they see enough to know whats on the list) -- and D/Cing inapropriate meds as needed--that should be addressed. You would not want to give a pt with a hx of a GI bleed 2 months ago or a head bleed 1 month ago aspirin or Ibuprofen and the doc should be adjusting the standing orders for stuff like that. Hope this helps and yes the docs do miss things which is why the nurses are part of the team to help catch things like that, and just address it with the MD. And using nursing judgment as well.

Otessa, BSN, RN

Has 19 years experience. 1,601 Posts

When standing orders have been used I would write "per standing orders, Dr.so and so, OtessaRN".

Where I have worked the standing orders were minor ones-Tylenol, bowel care, sleeping aides.

DeeAngel

820 Posts

Where I work if I want to do something that is a hospitalist standing order, I put in the order on the computer and instead of clicking on "verbal telephone order" I click on "per protocol" and put down the assigned hospitalist's name as the Dr. who needs to sign the order. There is a space to make a brief note as to why you are placing the order and I always fill that in. Lets say that it's a standing order to type and cross everyone with an H&H below a specific value. I would place the order for the type and cross, note that it was for the lab values of Hemeglobin_______ and Hematocrit of _______ and then note "per protocol" and sign the order with the assigned hospitalist's name.

Residents are one step below the attendings and really do the attending's work for them on their patient's. Residents are assigned to a service like a surgical resident for example and they in turn will have interns that are on their surgical rotations work under them. The residents are in charge of the interns that are going through that particular service in their clinical rotations.

Belle Epoque

156 Posts

I'm confused by this: "Now I have not been doing this because in nursing school we were always told to call the dr before administering something, but is a standing order different."

If you were to always call the dr before administering meds, you'd have a strip torn off you pretty fast! If your nursing instructor told you that they are seriously out to lunch. A dr's order is already your "permission" to give the med or treatment or whatever it is (based on your knowledge, skill and judgment) so you shouldn't be harassing the docs for something he's already written an order for unless you need clarification or are disputing the order.

Standing orders are guidelines for treatment or med administration for patients who meet a set criteria of stipulated clinical situations.

elkpark

14,633 Posts

Everyplace I've ever worked, any "standing orders" or protocols have been written down somewhere -- whether that's pre-printed admission order sheets, a file of different physicians' standing orders, or some other mechanism. Usually, these are required to have gone through a process of being approved by the overall medical staff of the facility.

I would not give anyone anything on the basis of simply being under the impression that that's what the physician usually wants in that situation -- without a written standing order/protocol or a verbal/telephone order. If anything goes wrong, the physician can (and, often, will) simply refuse to back you up, and then you're left dangling in the wind.

I'm with Otessa; assuming a actual written protocol or set of standing orders, I would write the order in the individual client's chart as "per standing orders Dr. XYZ/elkpark, RN". I would never document in a chart that I telephoned and spoke with a physician when I didn't actually do that.

ocean waves

Has 35 years experience. 143 Posts

Hello. Regarding "standing orders"-- When I was working on a cardiac unit, some of the groups of cardiac surgeons gave us printed, pre-signed, "standing orders" for post op care of cardiac bypass patients. These standing orders were considered the same as any verbal or phone orders and there was no requirement to call docs before following these specific orders. Regarding "hospitalists"---it is my understanding that hospitalists are doctors who have completed their medical training, work independently, and have chosen the fairly new specialty of practicing in hospitals (in contrast, residents have completed medical school but are still in clinical training for their specialty; they work interdependently with private physicians or with the medical director of the particular department). Best wishes!

roser13, ASN, RN

Specializes in Med/Surg, Ortho, ASC. Has 17 years experience. 6,504 Posts

I'm not quite sure why your manager wasn't more supportive. It is his duty to ensure that you're clear on your standing orders/protocols.

Standing orders are NOT telephone orders. In fact, it would be downright wrong to list a standing order as a telephone order, which implies a spoken conversation with a physician. Standing orders are orders that are printed into policy and which can be undertaken without consulting the physician. Whenever I invoke a standing order, I make certain that a copy of the referenced order is on the chart.

Again, I'm very puzzled by your manager's inability to help you understand your facility's policies and procedures.

PedsAtHeart, LPN

Specializes in LPN, Peds, Public Health. 375 Posts

Agree with Otessa and elkpark.

Anytime I go from standing orders, I also chart such and such per standing order Dr so and so...

I would never document telephone order if I did not telephone the Dr.

Thats what standing orders are for, so that you can use your nursing judgement and not have to call the physician for every little thing.

DG5

Specializes in Med/Surg, LTC. Has 11 years experience. 120 Posts

Also ditto to never writing down that an order has been received telephonically when it clearly hasn't, I would also never accept an order over the telephone from a doctor or hospitalist that would say for eg: "Sepsis protocol" because as it has been pointed out in previous posts here, those kind of orders have a list of alternatives that the doc would cross off or tick as appropriate and who am I as a nurse to know which are appropriate or not? Usually, a telephonic order is taken either when a doctor calls it in, or when a nurse phones the doc to request one, and in that instance, it would be for more specific interventions until the protocol can be reviewed and signed by the physician personally.

caroladybelle, BSN, RN

Specializes in Oncology/Haemetology/HIV. 5,486 Posts

All standing orders should be written down somewhere. And there should be a notation in the individual pts record that nursing is permitted to use those orders with the pt. Otherwise, they are probably not legal.

Various regulating entities have tried and want to eliminate "standing orders" as many consider them illegal unless written individually in each pts' chart. They are also dangerous - I actually have experienced medical errors personally on 3 occasions from nurses who instituted "standing orders" and offered me meds containing a common product that I am anaphylactically allergic to (I refused them) You will rarely find standing orders in teaching facilities that are more highly regulated .

dthfytr, ADN, LPN, RN, EMT-B, EMT-I

Specializes in ER, Trauma. Has 30 years experience. 1,162 Posts

Since you've already been given excellent advice about standing orders, I'd like to clarify something about residents. Where I've worked, residents (and their posse) are considered to be in training, while a licensed nurse is in practice. The difference is that if the resident gives you a dumb order, and you follow it, the resident is told to go study that subject again. You are responsible for the error.

I replaced a nurse who was fired mid shift for following an order to give a patient in the CT scan 100 mg of sucinylcholine (sp?) iv for pain. The patient wasn't yet intubated, and died soon. The surgical resident was told to study pain vs paralyzing meds and the nurse was escorted off the property. If my understanding about this is wrong, I'm sure I'll be quickly made aware.:up: