Published Mar 18, 2005
Can a nurse write a T. O. order for X-ray ( fall) or psych consult without first calling the MD? I saw this discussion today at work , and I couldn't really decide? Emergency, Nursing judgement, MD not returning call?
Legally - no. Some nurses do this as they know the MD will back up the order. But unless it is part of a protocol or standing order, you need to call the MD.
i don't know what the BON says about it, but i have done it many a time in LTC when i cannot get in contact with the md and a fracture needs to be ruled out. i have never had any problems doing it.
KRVRN, BSN, RN
No, a nurse can't write a T.O. for something that they haven't actually received a T.O. for. I've seen a nurse be fired for doing so because she wrote a T.O. for an order she thought the doctor would be okay with. He wasn't okay with it and she had no legal ground to stand on. Use caution if you do it.
No, a TO is just that -- a physician's order received over the telephone. I, too, have seen nurses get into serious trouble for writing TOs on their own that the doc wouldn't back up. It's illegal, it violates lots of rules and regulations, and the nurse has no leg to stand on if caught.
If the doc is not available to you in an emergency situation, that is a whole 'nother problem that needs to be dealt with by the facility administration.
Dixielee, BSN, RN
I agree with above. Nurses in certain areas get away with ordering much more than others. ER, PACU, ICU where the nurses work with a specific set of doctors and many times have written protocols already in place have much more freedom. I think if you are in doubt in a LTC facility and you deem it an emergency, then send them to the hospital. It is a shame that we have to do that sometimes, but with the world being as lawsuit happy as it is, I would not risk it. My license is too valuable to be left to the whim of a doctor who may or may not agree with my judgement.
Antikigirl, ASN, RN
Yep, TO is an order recieved over the telephone by the MD themselves.
When I have urgent situations that need immediate intervention and a doctor is not available, I am within my rights to have EMS intervention as part of my nursing judgement, and being the senior most medic in the building (a state good samaritain law we have...and a mandatory help law for medics). So I try to get a hold of the MD, document how many times I called and how long I waited, and if need be I call 9-11 for immediate interventions.
The trick is I document all of it very carefully, really pointing to the reasons why I found it necessary for immediate EMS intervention, and why I was unable to reach or take the time to reach the MD. Sometimes trying to reach the MD is seen as neglect in situations because you delayed treatment...so you have to really learn to guage the urgency and make the choice. Sometimes that choice is soooooo hard, but I have learned to trust my gut, and have yet to be wrong!
The regs are clear..you HAVE to have an MD okay the telephone order....but real life is real life. Most of the docs I deal with don't have a problem if I write telephone orders for either dietary recs or pharmacy recs, or if I think someone needs an x-ray. I've known them all for years and we have developed trust. I'd never write a telephone order for a med, but other than that, I write 'em and let the docs know. We use the fax machine for almost 75% of our TO's. It's quick and easier for the docs than being on the phone all the time.
CoffeeRTC, BSN, RN
Sounds about what I do. Ours will okay therapy orders, clarification orders, urine R&M C&S. Also one time cough med, MOM, Tylenol...these need called to the doc to rule out other issues, but a first dose they will okay.
The facility I work at has about 10 MD's for the 42 residents on our floor. About half of them have no problem with nurses ordering UA's, X-rays, some labs. The other half have to be notified for everything even down to a single tylenol for a headache. We respect their wishes and we all get along just fine. LTC MD's seem to understand that we don't want to bother them with things that need done. Illegal?? More than likely, but that's the way it is.
I work in LTC. We have a book of our house doc's protocols...which saves a lot of time. But none of us would write an order for a psych consult without running by the MD first. Same with x-rays, unless it's an emergency...then we just call for transport to a hospital. We've had a couple pretty obvious hip fractures lately...we call for transport then notifiy family. The MD is notified after we've seen to our resident. He's pretty easy to get along with.
Just a little something I go by: when in doubt, send 'em out.
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