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?

[Spatialized]

I've taken VOs in emerging situations, but gave the MD the chart right after saying, "Can you write that for me?" As a night shifter, while we have house officers in-house all night, they cover the entire hospital and do all the admits from ER to the floors. 9 out of 10 times, they're nowhere near the floor so TOs are the orders I usually get. For med and lab orders, there is a box to signify what kind of order it is when we enter, it then pops up on the MD's profile for them to sign (in case of a TO) when they log back on. So it is written, at least by me, and I always read it back, to make sure we both have it right.

When I worked in LTC, I took TOs on weekends in cases where the orders needed were not already standing/pre-printed orders. I t worked then as well.

Cheers,

Tom

[Roy Fokker, BSN, RN]

VO/TO?

No Doc on the floor gives us VOs - except for the ones who've been here 30+ years and are used to doing so (and management doesn't pressure them to mend ways). I have a habit of writing VOs down on scrap paper (just in case) while I bring over a Physician Order sheet for the Doc to write it down on.

Sometimes, when I've been too busy, on occasion I re-copy the VO and write it down as a TO.

I apologize if this has been addressed earlier, but I just had to share my thoughts:

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.

Perhaps this is simply difference in practice between US/UK, but here:

If I put a heating pad on a surgical patient (say an abd. hysterectomy) without a doc's order, there'd be heck to pay! Sometimes, something that may seem very "routine" (e.g. Ice pack on fresh post op joint replacements) can lead to trouble if done without doc's approval.

Many (if not most) treatments require a doctor's order to be implemented. Luckily, we work with a fantastic bunch of Docs (80%) of the time - they trust our judgment in regards to many things.

cheers,

[P_RN, ADN, RN]

Our hospital got sued for like a bajillion $$ for a severe burn from a heating pad, therefore NO heating pads.

I sure wish our orders had been computerized. We had a couple of doctors who couldn't write worth a darn and it was terrible to try to interpret.

As far as verbal orders, I had more than one go-round with this one doc who coulnd't understand why we couldn't honor orders he called in from Bolivia, Grand Canyon river rafting, London Gatwick etc. He was a nice guy but sheesh.........he was also one who wrote like a drunken duck.

[BittyBabyGrower, MSN, RN]

No verbal orders unless it is in an emergency, we rarely have TO as we have residents around all the time.

[DEB52]

Thanks for letting me know that we are not the only one's doing this. When I was at work yesterday ,I heard that the residents were calling nurses on the phone from down the hall to give them to orders so they didn't have to write them. I think this is going to be a long and hard transition for all. Even the nurses are complaining about the change. They don't seem to get it that's it's their license on the line.

[HelenofOz]

As I work in Recovery verbal orders are not an issue-the anaesthetist is there so he's writing.

For phone orders in New South Wales the Health Department regulations state that the phone order can be received by a pharmacist, medical officer or registered nurse and then read back by that person, and then another person is to also hear & read back the order. It is recorded in the appropriate area of the chart set aside for phone orders and signed by both people taking the order, and the original prescriber is to sign within 24 hours.

We have a career M.O. on site 24 hours and in this case he/she would have contacted the surgeon or anaesthetist for orders for treatment where an issue arose.

[shellsincanada]

The heat and ice, transfer from LTC to ER unless absolutely dire emergency, even a bandaid, for God's sake - all are by MD order where I work in America. Maybe different in UK. Not all hospitals here have on-call docs in-house, certainly nursing homes neve do. Even in hospitals that have on-calls docs in-house, they are not likely to come see the patient unless it is a serious situation. They just give phone orders.

Wow - a bandaid? omg. We can decrease the frequency of wound care- that is a nursing decision for us. ( docs always seem to like daily when it really doesn't require that)

We have a wound care best practices team that will order ABI's and do things like change dressing orders- then fax the doc for confirmation of our changes. Putting a dry sterile dressing on any wound is something any nurse can intiate. Vitals, frequency of nursing visits, things like this our considered nursing decision.

Sounds like we have way more nursing decisions- granted we aren't sue happy america though.

I work in the home so half the time the patient comes home with a new RX in a bottle from their dr's appt and we will fax the order to the dr or get the pharmacy to send us a photocopy of the order. I never take verbal orders - if the doctor is in the home ( rare - seen it a couple of times while I was there)- he can write it out. Telephone orders- all the time- along with faxed orders.

[vernRN]

No verbal orders are to be written at my facility. Telephone orders are acceptable, since the physician is not present on the floor during the night.

[nici1978]

unless there is a code going on no verbal orders from the doctor

has been that way since years, also the telephone orders were always read back

nici

[Kthale81]

When taking a verbal order or telephone order, it should have RB (Read Back) after the nurses signature. Most physicians that come to the unit will write orders, even though the nurse was informed verbally. Although there is a physcian that expects everything done for him, such as take verbal orders, write a progress note and call in RX) A nurse rounds with the physician, usually the charge nurse. At the facility I was working about a month ago, had standing order sheet for physicians. If the patient needed something (nausea, sleep) the nurse would just get the standing order book and initiate the order. Standing order would be SO doc/nurse sign the order. Also if a pysician writes an order such as mild ss log insulin, we pull the order sheet and select as ordered, then that was a WO doc/nurse to sign the order. Every facility is so different, even units in same hospital can be a little different.

[Kthale81]

The hospital I work at is 100% computerized, no paper. We have been doing this as well, difficult to ascertain verbal vs. T.O. since all SPOKEN orders are verbal orders. We have a prompt on the screen that the order was read back to the MD, and a prompt to differentiate verbal or T.O. I always put verbal, that's what it was, a spoken order.

Oh how wonderful to not have overwhelming sheets of papers. I get stressed b/c of all the paper, it is scattered everywhere so nurses can't find their stuff where is was left at the spot to do patient care.

I missed the computer when I went back to paper world b/c of my illness.

[Laughs-a-lot, RN]

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

I am a newer nurse just licensed last August. I'm not sure I understand what is meant by losing your license over a med that wasn't prescribed. Is this to say that if the physician gives me a telephone order for a medication and doesn't sign the order until the next day or so, then it is technically not legal? Or is this on a different track altogether?