Verbal orders

[Cg831]

Calling all experienced critical care nurses for advice!!!

I am a travel nurse who works in Intensive care with 4 years of experience. I feel I have a decent amount of experience from working at a variety of different sized hospitals but I realize there is still a LOT to see as my career continues. At my new assignment nurses in the ICU are expected to take verbal telephone orders for MDs for EVERYTHING and enter them in the computer. Controlled substances, sedatives, vasopressors, restraints……. literally anything the overnight hospitalist wants ordered. It is the smallest facility I have worked at and there is no physically present intensivist available at night. I am very uncomfortable with this but the staff urge me to do it and seem annoyed when I ask the charge nurse to enter the verbal orders for me. I am simply trying to avoid liability from a practice I thought was improper and violating nursing standards.

I am reaching out to my professional community for advice. Am I wrong? And please be honest. Am I misunderstanding the situation based on the available resources of this community hospital? I really want to understand the legality of my situation from a very factual standpoint.

I enjoy the location, patient population, and the staff I work with and don’t want to become someone who they don’t want to work with. However, I want to uphold my professional responsibility to the highest standard possible and not leave my license vulnerable. 
 

Please let me know if you have any experience with this!
 

[dianah, ASN]

Moved to Critical Care area, for better exposure and potential responses.

[JKL33]

On 10/1/2022 at 1:27 PM, CMRN1221 said:

I am very uncomfortable with this but the staff urge me to do it and seem annoyed when I ask the charge nurse to enter the verbal orders for me.

Why would another nurse enter verbal orders that you received?

 

On 10/1/2022 at 1:27 PM, CMRN1221 said:

Am I misunderstanding the situation based on the available resources of this community hospital? I really want to understand the legality of my situation from a very factual standpoint. 

 

Neither verbal nor telephone orders are illegal.

The situation at your place is likely due to a combination of accepted culture/practice and resources. They probably could have the overnight provider log on and enter the orders from home, but there could be fairly legitimate reasons why they aren't requiring that. 

Things often are not as black and white as we are led to believe.

There are safer and less-safe ways to take verbal/telephone orders. If it is not a responsibility that you want, you would need to choose to leave that contract or try to press the matter of making the provider enter orders from home.

 

[EOC, MSN, RN]

Look into your state's Board of Nursing's scope of practice. See what they say about verbal orders. Verbal orders are usually for true emergencies only. For example, the MD is in the middle of intubation.  Does this hospital have an EMR? If that's the case, then the MD will have access from home to place orders. I have worked in small hospitals where culture plays a role. Changing it takes time. However, you must be mindful of your license too. 

 

[Cg831]

Thank you for your responses. Yes, there is an EMR and I'm pretty sure culture is the biggest issue here. The physicians would rather do less work and have nurses enter their orders, somehow the staff nurses here believe it is a normal way to practice. This is the only hospital I've worked at where this is acceptable and I have only worked in ICU since I became a nurse. I have worked at university hospitals as well as community facilities and it was always totally unacceptable for an RN to enter physician verbal orders. I also remember this from college. I was unable to find a clear answer when deciphering the CA nurse practice act information. It's just amazing how culture can play a role in the way a facility practices. I've been here long enough to see how it creates poor outcomes for patients as well. (Physicians start to think nurses will just enter orders for things they need without consulting them at night, physicians won't check up on lab values or I&O balances). I believe as a traveler it will just be one of those situations to learn from and ask about on my next assignments interview process. 

[akulahawkRN, ADN, RN, EMT-P]

It is preferable to have the physician do the order entries themselves if they have EMR access from wherever they may be. It is not the only way that orders may be entered on behalf of a physician and still have these orders be legal. The physician will still have to sign the orders at some point and if these are entered into an EMR, the system should bug the physician to sign orders that were entered as "verbal" orders.

The hospital should have a policy regarding verbal/telephone orders and you should definitely look that up. Where I used to work (I'm an ED RN) the triage nurse was expected to place certain orders for labs and imaging before the physician saw the patient. About the only stuff that couldn't be ordered by triage were things like CT/MRI/Ultrasound scans. Basically anything "expensive" was a no-go but relatively cheap/routine stuff, sure. Those were always signed later by the physician. Where I'm at now, emergent verbal orders and 12-lead EKG orders are about the only things that I can do on the physican's behalf. They're expected to do their own EMR entries. In both cases, the hospital has a policy about this. Unit culture is a thing but if there's an official policy, follow that. 

[Cg831]

akulahawkRN said:

It is preferable to have the physician do the order entries themselves if they have EMR access from wherever they may be. It is not the only way that orders may be entered on behalf of a physician and still have these orders be legal. The physician will still have to sign the orders at some point and if these are entered into an EMR, the system should bug the physician to sign orders that were entered as "verbal" orders.

The hospital should have a policy regarding verbal/telephone orders and you should definitely look that up. Where I used to work (I'm an ED RN) the triage nurse was expected to place certain orders for labs and imaging before the physician saw the patient. About the only stuff that couldn't be ordered by triage were things like CT/MRI/Ultrasound scans. Basically anything "expensive" was a no-go but relatively cheap/routine stuff, sure. Those were always signed later by the physician. Where I'm at now, emergent verbal orders and 12-lead EKG orders are about the only things that I can do on the physican's behalf. They're expected to do their own EMR entries. In both cases, the hospital has a policy about this. Unit culture is a thing but if there's an official policy, follow that. 

Thank you for your experience based answer. I really appreciate the insight. As crazy as this sounds..... I have no access to the unit policies. I am told that travelers don't have authenticated log ins to access it. This facility is in a very underserved community and the practice and culture at this facility is not a help. I would love to hear from more ICU nurses about their experiences with this. 

[akulahawkRN, ADN, RN, EMT-P]

Cg831 said:

Thank you for your experience based answer. I really appreciate the insight. As crazy as this sounds..... I have no access to the unit policies. I am told that travelers don't have authenticated log ins to access it. This facility is in a very underserved community and the practice and culture at this facility is not a help. I would love to hear from more ICU nurses about their experiences with this. 

The travelers I work with also don't typically have access to our hospital / department policies but they can ask regular staff to access it for them. If any of the travelers I work with asked me, I'd happily pull it up for them and print it out, as long as the system lets me! If nobody will do that for you, take those T.O.'s and ask another RN to listen to/verify the order, do the entry and note who also heard the order and when your contract is up, go somewhere else if you're still uncomfortable with that practice.  It's not illegal, just less preferable and should be done less and less frequently. 

Telephone Orders are still quite common in the Skilled Nursing Facility world... take that for what it's worth.

[JKL33]

Cg831 said:

The physicians would rather do less work and have nurses enter their orders, somehow the staff nurses here believe it is a normal way to practice.

You're likely not completely wrong on that, but probably oversimplifying. You say this is a small, underserved place. Things aren't going to be like they are at a tertiary facility. Depending on the pay and other factors, they may not be able to find enough coverage without some compromises. It's even possible they don't have a dedicated service but just someone covering nights, for example, who agreed to do so under certain terms.

I have seen this change over time at one of the places I worked, but not until the smaller place was sucked up by a corporation whose solution was to staff the "ICU" and "hospitalist service" with new grad FNPs--yes, not ACNPs but brand new FNPs who had to practically call 911 if their patient seemed to be having a problem.

You can look into your BON/Scope in your state as mentioned above, but I doubt it will outright state that verbal orders may only be accepted in true emergencies.

This is usually perceived as a physician vs. nurse issue, but really it's a matter between the hospital and the physician and the hospital and the nurses. The hospital is offering some level of physician compensation to cover their basic needs at night, and it does not include the physician being on the computer all night....because they have chosen to say that their employees (nurses) will take care of that aspect. That is likely part of how they managed to get the coverage (at that particular price point).

[Nurse Alexa, MSN, RN]

Verbal orders always make me uncomfortable! It is important that you are comfortable with that certain HCP to be placing them in the computer for him or her. 

The best way to place verbal orders in is by using the readback method - noting each characteristic of the order. If the order is not readback appropriately, something may be missed or misheard which will then affect the patient's care. 

In my opinion, I have only felt comfortable utilzing verbal orders in my home hospital, where I worked for 7 years - I know we all have each others back.

I have done a few travel contracts at this point and would never agree to a verbal order just because I do not know the attending's as well. Use your judgement and feel out the situation. See what's right for you ?