Telephone Order or Not??

[Jennifer_RN2013]

Hello Everyone! I have a question about "telephone orders". I just started working for a long-term care facility and I am having some trouble with these telephone orders. I only have 4 days orientation and I am a new nurse. I work the 3-11 shift and it seems that when people need an order for something like a catheterization, UA and C+S.... they just write it down as a telephone order even though they never notified the doctor. The doctor just comes in and sign them when he can. To me this seems wrong... very wrong. Has anyone else ever heard of this? I feel uncomfortable and I am not sure how to get a hold of a physician when I work 3-11? They won't be in the office. The nurse also write orders for treatments like flushes after IV treatments, PEG Tube flushes, etc.. Any advice would be much appreciated!

[chrisrn24]

Did you not go through orientation??

There are on call physicians to call for these orders. And also -- you may have standing orders for certain things, like UA/UCs. I don't but maybe you do.

You need more training - plain and simple. Please approach your supervisor with these concerns.

[Jennifer_RN2013]

My orientation is only 4 days!!! It is usually 3 days and I asked for more and got one more day. There are no standing orders that I have heard of, and I thought the same thing about the physicians on call. It doesn't seem to surprise my DON that this is occurring. We are responsible for ancillary orders for treatments too, and I have not seen one person call the physician!

[MunoRN, RN]

You don't actually need orders to flush an IV or to flush a PEG, these are within the scope of an RN and are the standard of care with either of these treatments (an order for an IV med includes an order for a flush regardless of whether or not that is specifically written by the MD).

Your other examples though are bad practice if they are not being initiated based on standing orders or protocols. I realize Doctors don't like to be called in the middle of the night about a patient who clearly needs to be cathed, but that's why protocols need to exist to handle that, if none exist it's up the Nurse to call, if the MD doesn't like it then it's up to them to get protocols in place.

Are you sure no protocols exist or you just aren't aware of any? Some facilities do initiate their standing orders/protocols by writing an order from the primary MD, sometimes writing "protocol order for Dr. so and so" but I have also seen "T.O. Dr. So and so" as the official way to write these orders.

[amoLucia]

PP MunoRN is correct. You SHOULD have Policy & Procedure manuals that cover standing orders. These standing orders have been already reviewed & pre-approved by the facility's Medical Director. Your IV manual covers your flushing protocol; your Infection Control manual prob covers protocol for when to obtain urines and foley cath care. GT tube orders are prob in the pharmacy medication policy protocol. Even your wound protocols may be governed by standardized house protocols unless something is specifically ordered.

Some places have simple Tylenol for pain orders and MOM, dulcolax, fleets protocol for BMs protocol. Pre-approved standing orders that you have a house-policy for.

So our orders is freq just our writing what has already been approved by virtue of pre-existing protocol in our manuals. But it's State regs that they still need to be written and signed off by the MD.

It's just that we experienced nurses already know what we have to write orders for because we know. (That's the luxury of being experienced at the facility where you work.) It just comes with time and getting to know your facility and your doctors.

NOTE: Not everything is a standing order. And some doctors can refuse standing orders and make their own. Rule of caution: when in doubt, DON'T. Never write orders for meds unless you absolutely talk with the MD.

Re your orientation. Ask your Inservice Nurse questions. Just be specific and ask one topic at a time.

[ukjenn231]

Sometimes if nurses "know" a doctor they might order some stuff without calling. "Oh, I know Dr. xyz, he would want me to just put in a UA." Or maybe sometime in the past the doc has said, "If this happens, go ahead and order this lab and call me with the results." This kind of practice makes me uncomfortable, so if I need an order, I will call the doc. That may be why people do that kind of stuff, but if you are brand new and you want to call the doc, then by all means call them. Especially 3-11, it's not that late. If you are unsure how to call a doctor, you can always call the office and if it's closed there will be a message telling you how to page the doctor on call. But, someone in the facility be it the secretary or other nurses, should be able to tell you how to page a doctor. I recommend finding that out next time you work, it's important - what if a patient goes downhill, you don't need to be panicking about how to put the page out.

Good luck!

[SaoirseRN]

Ask someone to show you the procedure for calling physicians during hours and after hours, as well as explain how your physician on-call set up works.

For example, we have an online list of physicians and their contact numbers (office, cell, home), as well as an online call schedule so we know who to call and how to reach them.

[Jennifer_RN2013]

Thank you all for your comments! I really do appreciate it. I will definitely ask about standing orders but as far as I know, we do not have any so I will be making a lot of phone calls!