Why Do Nurses Write: "no new orders received"?

Jolie, BSN · Jul 12, 2009

In the legal system however, if a nurse writes no new order received, it can be implied that the nurse thought new orders should have been received. It is best to write continue to monitor. This was from a conference I went to where a legal nurse consultant had spoken.

I respectfully disagree with this advice. Say you have a patient with a Hct of 5, who is pale, tachycardic, hypotensive, can't stand up without feeling dizzy and who doesn't have the energy to participate in ADLs. You report this to the physician who wants to continue with his present management of oral iron supplements BID. If you document that you will "continue to monitor," what exactly will you monitor for? You already have documented critical signs and symptoms of severe anemia that are impairing every aspect of the patient's life. What more monitoring is needed? For arrhythmias and chest pain?

I agree with the documentation of "No new orders received," if the nurse believes that orders should have been given. But it can't stop there. If a nurse is concerned about the lack of appropriate medical care, it is his/her duty to pursue that care on behalf of the patient. That involves going up the chain of command to charge nurse - nurse manager - nursing supervisor - medical department head, and documenting these consultations.

Any nurse who documents, "No new orders received," is documenting a disagreement with the physician, and had better follow that up by justifying his/her position in writing.

Scrubby · Jul 12, 2009

If I've told the doc anything about a change in the patients status I will document what and who I informed, and will always write 'continue to observe'. I have never seen or written 'no new orders received', probably more a US thing, but I think it's probably a good way to CYA.

And I also agree that if you strongly feel that something needs to be done, then you need to go higher up the food chain. You also need to document this process as well.

caliotter3 · Jul 12, 2009

I respectfully disagree with this advice. Say you have a patient with a Hct of 5, who is pale, tachycardic, hypotensive, can't stand up without feeling dizzy and who doesn't have the energy to participate in ADLs. You report this to the physician who wants to continue with his present management of oral iron supplements BID. If you document that you will "continue to monitor," what exactly will you monitor for? You already have documented critical signs and symptoms of severe anemia that are impairing every aspect of the patient's life. What more monitoring is needed? For arrhythmias and chest pain?

I had to comment on this example because this describes me perfectly one time, including the chest pain. Just reading it right now brought back bad memories.

nrsang97, BSN, RN · Jul 12, 2009

It is all about CYA. When I report something and the doc dosen't give me any new orders I say "Dr.Smith notified of (insert here) and no further orders received will cont to monitor pt condition." It lets whoever reads the note see that I called and reported, and didn't get any orders. Not a dig at the doctor at all.

Penguin67 · Jul 12, 2009

Any nurse who documents, "No new orders received," is documenting a disagreement with the physician, and had better follow that up by justifying his/her position in writing.

Well, I have to respectfully disagree with the above response. A nurse is not documenting disagreement when writing "no new orders received". The nurse is documenting a fact. Period. If you disagree with the MD, the place to do that is certainly NOT in the patient's chart. If the nurse thinks that orders are warranted for the patient, and hits a brick wall, then proceed up the chain of command until the desired orders are obtained. And, the nurse may be incorrect with what they want for the patient, and simply needs an explanation of why desired orders weren't given.

Vito Andolini · Jul 12, 2009

i don't write no new orders received, i usually write "no intervention indicated at this time" along with all the info pertaining to the patient issue including s/s, md notified, and general nursing f/u monitoring. i agree it is cya. it certainly is not an attack on the md from where i stand, as just as often i see in the notes, "notified by the rn" it is all just telling the picture like it happened.

if you write "no ...indicated...", you make it sound like you think no action is indicated. that's not what you want to convey, is it?

also, in a general response to the op and others, i see no problem with stating the truth - that no new orders were given. it shows that i know there were no new orders and that i will certainly continue to monitor or will continue to do whatever i think it will take to get proper care for my patient. i do not believe saying we notified a doc and that the doc gave nno covers us if we really think some no's are needed, if the patient is in trouble. if a pt needs help, i need to do all i can to get it for him.

i will notify the resident if i disagree with the intern. i will go to the attending. i will get my supervisor and the er doc involved. i will call the chief of the service if i am really concerned. i will document all along the way who i called, why, and the response of the callee and what i did next. i'll snag the doc's partner if he or she happens by.

do not think for a moment that simply telling a doctor once about a problem and letting him or her ignore it will cyb if the pt goes down. if i were on your jury, i'd find against you for not pursuing every available channel to help the patient.

Kwontor · Jul 12, 2009

Just a silly nursing school student question...what does CYA stand for?

Batman24 · Jul 12, 2009

Just a silly nursing school student question...what does CYA stand for?

Cover Your Ass.

flightnurse2b, LPN · Jul 12, 2009

i always write "no new orders received" if i call a doc for a change in pt condition and they do not give orders. i agree with cardiacRN--if they don't like it, too bad. i'm covering my butt. it's not disagreeing with the doctor or trying to make them look bad... it's showing that i was appropriate in reporting what i thought was important enough to call a doctor for, that the doctor is now aware of the situation, and does not want to change the plan of care.

Babs0512 · Jul 12, 2009

I only write "no new orders given" IF I have reported a potentially serious problem to the physician, and he/she didn't do anything to correct the problem. IE: patient reports pain as 10/10 - BP elevated 145/90, Vicoden given per order, pt reports "it didn't help". MD aware. No new orders given. That helps to cover my butt as I did try to convince the MD to order something else, but MD chose not to. I would then try pallitive measures, like warm/ice pack, repositioning, whatever, if after trying some other interventions, and pain persisted, I would call MD again, and document as such, if I still got no where, I would then be forced to go up the chain of command.

That's just one example.

Blessings

Vito Andolini · Jul 12, 2009

I do legal consulting and would never interpret "no new orders received" as "Gee, the nurse thinks that something more should be done and the MD won't do it". I would read that as, the nurse called in a change in the patient's condition, perhaps an out of whack lab value, and made sure that it was documented that the MD had no further orders based on that data. It is way too easy for the MD to come back later and say "I told that nurse to do such and such, why wasn't it done?". I would also suggest writing the "repeated/verified" after all verbal phone orders, to show that you gave the MD time to review it, so there will be no discussion of an order interpretation problem later.
One situation that I am reminded of happened many years ago. A patient with spina bifida had an IV in his leg, liked having it there because he couldn't feel it. (In retrospect, no a good idea to even place it there, but the IV team did that.) Anyway, he was to receive dilantin, I think, IV slow push. (This was many years ago.) The nurse who gave it flushed the line with saline, checked and had good blood return, then gave the med. While giving the med, the patient's skin near the site began to turn black and the nurse called for the rest of us on the shift to come in to check. I saw a quarter size black area when I walked in. The nurse called the patient's primary MD, who ordered, over the phone, a warm compress. You can probably guess what happened. The site infiltrated with a caustic med, which was enhanced by the warm compressed which were ordered, and by the time we got there the next day, her foot was blistered with a bad burn and she was being treated with burn dressings, maybe silavadene? Outcome? The patient lost his foot a few days later. The MD? He denied ever giving that order. Cover yourselves with "repeated and verified" as well as "no new orders received".

How does it cover you to say "repeated and verified"? The doc can still deny the whole thing.

I think VO's and TO's should absolutely never be taken except in a dire emergency. Whenever a VO or TO is taken, there should be a witness on the phone who co-signs immediately as having heard what the doctor ordered. That's not foolproof, either. Maybe there need to be cameras and microphones everywhere to record every last action and word.

The Dilantin IV story above - did the nurse tell the doctor what had infiltrated or only that an IV had infiltrated? Was the presence of gangrene told to the doctor? What was the final outcome for the nurse? for the doc? for the hospital?

hypocaffeinemia, BSN, RN · Jul 12, 2009

Our MD Notification note in our EMR forces us to choose yes or no to "New Orders Given?" on every notification.

Of course, here in the ICU very rarely do we not get the patient's needs addressed. A couple of our internists will even just tell us to write what we need and then they sign it (I only do this if they're on the unit so I can have them review it).

Pretty decent collaboration all in all in our unit, but we have no med students or interns/residents nor do we have 24/7 in-unit intensivists so the docs rely on us extensively.

And we have a bit of leeway for taking action-- just this morning I had a patient who's pressure was 70's/40's and falling on a maxed out neo drip so I had our secretary send out a page while I started a NS bolus and mixed up a levophed drip and hung it. There's not exactly time to sit around and wait for a return page in such cases lest we rather just wait for the patient to code.

Of course, you alert the doc of your actions and get their verbal okay for them, but saving the patient's life takes precedence.