Standing orders (Please explain)

[ScreamBoxDolly]

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 )

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?

[Belle Epoque]

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 .

I disagree. I work in a large teaching hospital and we use standing orders and clinical pathways all the time. If anything, we use them more than ever. It's a very efficient way to streamline care especially for those conditions which you see repetitively on your unit ie) post op hip, lap chole, hyst, whatever. Remember that it is the physician who initiates them based on a specific set of criteria the patient must meet so if you somehow were given meds that you were allergic to, then the physician dropped the ball by not doing a proper assessment on you and initiating the standing orders when obviously you were not a candidate. Of course, this can also happen with a regular order.

For the record they are perfectly legal and as good as "written individually in pt's chart" as ours are addressographed per patient and included in the chart.

[Belle Epoque]

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.

Our residents might be in training but they are still doctors and hold many of the same privileges as the attendings. We take orders from them in the same way. As for following dumb orders, we ARE responsible whether written by resident or attending. No difference.

Med students are NOT allowed to write orders w/o a co-sig and we don't follow orders from them which makes it monumentally important to know the docs you're working with because no one will protect the nurse if some cocky med student decides to play doctor for a day and writes his own order. Of course you wouldn't run into this problem if not working in a teaching hospital.

[Kooky Korky, BSN, RN]

resident physician = a doctor who has finished med school but is not yet an attending, because he has not completed residency

residency = usually 2, 3, 4, or 5 years, depending on the specialty (surgeons must spend many more years than psychiatry or Internal Medicidine, for instance); go to a website from a university that has a medical school and see what it has to say about residency; also known as PGY2, PGY3, PGY4, and Chief Resident (there is only 1 Chief per year per specialty; being Chief is quite an honor);

intern = an archaic word; now is known as PGY1 = post-graduate year 1 = the first year after medical school graduation; a licensed doc but a beginner doc, who knows a lot from studying but very little from experience;

fellow(ship) = this comes after residency; I see Cardiologists and GI docs do it a lot; so much to learn; I don't think all specialties have Fellowships.

attending physician = a real live doc in private or group practice;

hospitalist = a real doctor who works in a hospital, maybe employed by the hospital; cares for patients in the hospital only; not sure how many years of residency/fellowship they have done;

intensivist = a real doc who cares only for patients in ICU; see hospitalist re: their training and who employs them;

Not sure but wonder if Intensivists and Hospitalists might have a private practice and are asked by a patient's attending doc to see and care for the attendings' patients in inpatient settings, as described above

re: standing orders; These are also known as PROTOCOLS. When I worked in a correctional setting and then in ICU, we had Protocols. There were several protocols. For example:

stitch and staple removal

Tylenol and Motrin for aches or fever;

MOM for constipation; Mylanta for heartburn, nausea;

Benadryl po or cream or Calamine lotion or Hydrocortisone cream (OTC strength) for itching;

UTI phenazopyridine

lady partsl infection (Monistat)

tolnaftate or lamisil powder or cream for athlete's foot;

There was a protocol for lice, one for scabies, another for menstrual cramps, and there were lots more that don't come to mind just now, but hopefully you are getting the idea. All the meds were available over the counter,

except the dental pain protocol. That one was for PCN & Motrin/Tylenol. Erythromycin could be substituted if there was a PCN allergy.

We had something for bee stings, one for cuts and scratches, one to allow steri stripping and giving of a tetorifice shot.

Protocols allow the nurse to assess a patient and make an actual diagnosis and pick the right treatment. There was quite a lot of controversy about nurses actually diagnosing and initiating a protocol. If you felt uncomfortable using the Protocols, you were free, sort of, to get a phone order instead, although the doc you had to wake up and your supervisor were not happy that you didn't use the Protocols.

We just wrote the protocol onto an order sheet and transcribed it onto the med sheet and jumped in using it, doc signed the order sheet upon his next arrival to the ward. The supplies we needed were readily available, no waiting for Pharmacy.

The Protocols all called for the patient to be seen by the first available MD to arrive on the ward. Protocols were countersigned by this doctor at that time and were either extended, stopped if the problem was over, or changed. Unless a nurse had seriously gone astray and chosen a laxative to treat skin itching or something goofy like that, no nurse was ever in trouble for using a protocol in the many years I worked under this system. We loved being able to use our brains and bring quick relief to our patients.

[ScreamBoxDolly]

Thanks for everyone's replies!!! I appreciate it~

So basically in a nutshell standing orders are in place so I don't have to call the dr (bassed on my assessment of the situation and is not contraindicated), BUT I should write Per Standing Order/Dr so and so/AMillerRN. And that is legal right?

[Kooky Korky, BSN, RN]

i disagree. i work in a large teaching hospital and we use standing orders and clinical pathways all the time. if anything, we use them more than ever. it's a very efficient way to streamline care especially for those conditions which you see repetitively on your unit ie) post op hip, lap chole, hyst, whatever. remember that it is the physician who initiates them based on a specific set of criteria the patient must meet so if you somehow were given meds that you were allergic to, then the physician dropped the ball by not doing a proper assessment on you and initiating the standing orders when obviously you were not a candidate. of course, this can also happen with a regular order.

for the record they are perfectly legal and as good as "written individually in pt's chart", as ours are addressographed per patient and included in the chart.

i should think the legality issue depends on your state.

[Kooky Korky, BSN, RN]

Thanks for everyone's replies!!! I appreciate it~

So basically in a nutshell standing orders are in place so I don't have to call the dr (bassed on my assessment of the situation and is not contraindicated), BUT I should write Per Standing Order/Dr so and so/AMillerRN. And that is legal right?

I'm not sure why you aren't asking these questions at your job? I know you said you weren't getting a satisfactory response there but I think you really need to persist in asking your boss, not just each preceptor or coworker. Isn't there a written policy that shows you exactly how to write the protocols as orders for your specific patients?

As for legality, contact the state Board of Nursing and a couple of attorneys. Don't let your employer or coworker know you're doing it and don't give your personal or employer info to the Board.

My point is - there's got to be something in writing that you can follow, so you know you are protected.

[Kooky Korky, BSN, RN]

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 .

What regulating entities are you referring to? sorry you had such close calls.

[I<3H2O, BSN, RN]

At our facility we have a notebook with all of the doctor's standing orders in it. However, we are not allowed to use it until we get an order from the doctor to implement standing orders. It is really silly to even HAVE standing orders if you have to have a dr order to invoke it. lol

[ObtundedRN, BSN, RN]

I'm sure some of the previous post already state something similar to mine here.

My unit has a set of standing orders that are implemented for all patients on arrival to my unit. As mentioned before, anything that conflicts with the patient's disease or allergies would need to be crossed off. Being in critical care, my standing orders are for small things like tylenol, benedryl, bowel care. And it also has stuff for respiratory/nursing allowing us to titrate O2 as needed. It also allows me as the nurse to order chest xray and/or ABG for respiratory distress, 12-lead for chest pain, and KUB (abdominal xray) to evaluate any feeding tube placement when needed. It also has a few other things.

These orders are placed on the chart upon arrival to the unit. All the meds are added to the MAR by pharmacy and can be used like any other ordered med. If I get an xray or ABG etc when needed based on the standing orders, the I put "per standing order / my signature"

That standing order set is signed off by the MD at some point, and is considered the signature anytime one of those standing orders are used, so no further signature is needed. And if the MD doesn't sign the standing orders upon transfer/admitting to my unit, then we are to put it as a verbal or telephone order by that doctor, which they still need to come back and co-sign at a later time, but we can start using them right away.

[Chels911]

Im in nursing school too...so correct me if i am wrong. but isnt an order already the doctors "OK" to give the patient that medication or treatment?? if its on their MAR and is signed off by doctor and reviewed by pharmacist it is OK to give that medication. So you don't have to call them whenever you are giving medications. (Although i DO recal a nursing professor telling me that as well) So im confused why nursing professors tell us this---when i KNOW i the real world, if it is on their MAR, has been signed off by doc/pharmacists then it is OK to give that medication (And if it pt. meets requirements for it) Like if you are giving a BP medication and their BP was 80/40, a RN can sign off to "hold medication" then state the reason.

Now for standing orders.....Does this just mean that when a patient meets a set of criteria you can do a certain medicaion or this treatment. For example, if a patient has a temperature of 100+ then give Tyelnol....Or if patient cannot void 8 hrs after foley removal, reinsert Foley and notify MD.

So to me...it just means it is a set of criteria you can follow so you don't have to notify the MD everytime a patient spikes a temp or hasnt gone to the bathroom. Yes, they need to be made aware of it, but its no reason to call them at 4am. Its stuff that could wait till rounding in the morning or something.

Then if the RN has to use the tyelnol "per standing orders" she will give the tyelnol and there is an option that says "Per MD's Orders" because it IS his or her orders to do so if it is a standing order.

I dont know, thats just my take on it and what i have noticed and understand from it. But YES!! i HAVE been told the same thing you have by a nursing professor. Maybe misunderstanding what they mean by that??

[Airidis]

So if you had a standing order on a postop patient who returned to your floor 6 hours ago, and the dr's standing orders are : In and Out Cath if bladder scan reveals 380ml or greater if patient unable to void. Would you call the dr to confirm this order, or go do your bladder scan which would say yes, they have 600ml's in their bladder right now and they cant pee or nope, they only have 200ml, we'll wait and see.

Orders worded like that basically say you scan their bladder they have 600ml you do the In and Out because the DR has already approved it,

[ScreamBoxDolly]

My question though is that at the hospital I work at we have standing orders for the hospitalists (a sheet that states meds for bowel, bladder, blood cultures, etc), but they are not put on the chart when they come up. So in order for me to implement for every hospitalist pt, do I need to call the dr. Or can I just implement them since the hospitalists have standing orders?

I am getting both answers yes and no. In the end I guess I will save my rear end and call. Not the first time I have been yelled at lol.