Verbal orders vs Telephone orders

[DEB52]

There has been a recent change at our hospital on how we handle verbal orders. If the Physican is on the unit giving you verbal orders ,you are to hand them an order sheet and ask them to write them. If the doctor calls you on the phone , you take the order then read it back verifying the order.When you chart it you write "TO" to signify that it is a telephone order. It's been hard convincing the nurses and the doctors that this is the way it has to be done. The doctors have been informed in their meeting. How doe's your hospital handle verbal orders vs telephone orders?

[Myxel67]

Just as you described. If the doctor is there to give verbal order, he must write it. Telephone order must be written on order sheet and then read back to doctor. (Not just repeated back & then written when doctor hangs up). I think both are new JCAHO requirements.

However, If I catch a doc walking down the hall leaving unit, I'll ask for order needed & then write it as a telephone order. I don't make a big deal in this situation of having doc actually write order. If I have to, I'll call his cell phone or page overhead to please a picky manager or charge nurse.

[johnwaynehair, BSN, RN]

These are new TJC (the new & improved JCAHO) requirements: we got audited this spring and after the visit we were told the same thing; the only time we can take a verbal is if there's a code running.

[TazziRN, RN]

We've been doing it this way for a couple of years now.

[Spidey's mom, ADN, BSN, RN]

We've been doing it this way for a couple of years now.

Yep, us too.

steph

[nursemary9, BSN, RN]

We've been doing it this way for a couple of years now.

Same way, in Chicago, too

[kittagirl]

I'm assuming that by 'order' do you medication prescription?

Here in the UK, if it ain't written down it ain't legal.

While, yes there are certain situations that I will accept an 'order' over the phone it would be on me legally all the way no matter who else hear wittnessed it.

In view of that I always taught my students never to take a verbal/ telephone order.

Greyer area as regards care directions, eg; D/C a cath or I can't think of anything else right now yes we would take verbals, though a lot of the time I have to admit I would tell the doc what we intended to do and they would go along with it.

[TrudyRN]

We are not the doctors' secretaries. They can write it down if there is not a life-threatening situation they are dealing with right then.

As for never taking a verbal or phone order, Kittagirl, that is not realistic IMO. What if the doc is not present but you need an urgent order, such as pain or fever Rx or even a laxative or something for sleep or itching? Or what if the patient needs an ice pack or heating pad for comfort? Or an order to transport to ER from a nursing home or a thousand other things that cannot or should not wait?

The trouble with VO and TO is that, if the pt goes bad, the doctor can always come back and deny giving the order, which could leave the nurse blowing in the wind. That's why we want the docs to write their own orders wheneve possible. That said, there are always going to be circumstances when we have to accept a VO or TO and hope for the best. The best practice: get another nurse to listen in and co-sign with you as a witness to the fact that the doc really did give such-and-such an order. And/or get the supervisor or manager as a witness. Also, facilities should withhold docs' pay or even privileges if they don't co-sign within a certain time frame that the facility establishes.

[kittagirl]

Maybe this is a situation where the difference between the UK and the US can be seen. (I'll admit that I'm assuming that you're US based)

'What if the doc is not present but you need an urgent order, such as pain or fever Rx or even a laxative or something for sleep or itching?'

On an acute site you get the on-call doc to prescribe it. There is a medical doc on call 24hr on site to deal with situations such as this. In nursing homes etc, most in my area are trying to bring in 'care bundles' otherwise they would call the patients GP on call who are obliged to either visit or refer on usually to A/E (ER). Neither the nurse nor doctor would have any protection as regards a verbal order in this area

Or what if the patient needs an ice pack or heating pad for comfort?

Why would I need Dr to prescribe that? That would be a nursing decision.

AS for a transfer from a nursing home to an ER, again that would be a nursing decision.

But I do feel I really have to comment on your 'hope for the best', how can that be considered best practice? If the doctor is being paid to give his/ her opinion make a decision why aren't they there?

AS for doctors secretaries I never have and never will do a doctor's documentation for them. Not my job. Nor do we have unit secretaries, the most we have is a clerk that would only work office hours and is there to stock/ order nursing stationery, answer phones, make out-patient appointments and file nursing documents.

It is drummed in to us from the day we start nursing school that if it is not written down it is legal/ never happened. It is drummed in to us again by our unions that they can not and will not protect us, if we give a medication that was not prescribed.

I have witnessed a nurse lose their licence over this, yes they were possibly doing what was best for that patient, yes it was witnessed by another nurse, and yes the doc did come up to the ward the following day to prescribe the med, however in the mean time there had been an audit of the patient notes, this was picked up and as I said the nurse lost their job and licence.

This was a experienced nurse, no harm came to the patient, every one had the best intentions, but they did something illegal. That was the stand of the hospital and their union.

So for the convenience of one doctor, thousands of pounds in training cost lost and the a good nurse gone

[susan18]

I work as a correctional nurse educator. We discourage verbal orders as well, unless there is a life-threatening event transpiring. We hand the doc the order sheet, smile, and say, "Please just write it". For telephone orders, the nurse is required to read back the full order for clarification. This is safe practice. Then the order is written, and finalized at the end by :

T.O. Dr Jones / N. Nurse RN May 25, 2007, 1107

[Ladybugleaqueen]

I work in LTC and most of our orders are telephone orders especially on the weekend. As far as sending someone to ER being a nursing decision it isn't yes we may feel it is appropriate to send but ultimately we need an order to send.

[Dolce, RN]

We do that it that way, too. I've had MDs try to use me as there personal secretary to write out their V/Os. I just hand them the order sheet and ask them to write them down themselves. This is why electronic charting is such a good way to reduce mistakes--the MD can enter orders from anywhere with a computer. No telephone or verbal orders this way.