I always find it funny when the nurses call me for an issue they are having with the patient and then document "no new orders received." I have read that phrase is a dig at the doctor because you feel something is important and we aren't responding to your worries. Well, my job is to see the overall picture of the patient and if I don't feel the patient needs it, I won't order it to make the nurses feel better.
I don't think writing an order that says "no new orders received" is a dig on doctors. I think it's CYA medicine. A nurse is making it clear in the lawyer/billing chart that Dr Smith was notified of the low blood pressure, or the confusion, or the nausea, or the chest pain, or the INR of 2.3 on Coumadin, or the Hgb of 8.1 for the last six days, or the potassium level of 3.3 and they are making dang sure that their perception of a safety issue shifts all responsibility onto the doctor and off of the nurse. The extra emphasis of "no new orders received" seems somehow, in the mind of the nurse, to place an exclamation point on the notification.
But I don't blame them for writing it. I'm sure doctors all over this country have used the defense that they were never notified of the nausea or the chest pain or the low blood pressure and a bad outcome ensued.
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.
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This is standard practice in any ICU. You're right in that we have a lot more leeway..I can't tell you how many times I say "I've already started that" or "I've already done that" when I call important info to the Drs...
Of course, you know who to trust and who not to....
This is standard practice in any ICU. You're right in that we have a lot more leeway..I can't tell you how many times I say "I've already started that" or "I've already done that" when I call important info to the Drs...
Of course, you know who to trust and who not to....
That last line is true. Of course, it's a dilly of a pickle we're in-- practice medicine without a license or let the patient code before giving the same damn drug under ACLS protocol!
Luckily we have a ton of protocols here, but this patient was a new admit who didn't have any of them signed yet.
I always make note of any call to the doc, why I called, and his/her orders. If they give no new orders then I document everytime "no new orders received".
I agree it's a cya thing. Charting that no orders arent indicated at this time doesnt really put it out there that the doctor stated none indicated. It implies "our" opinion. This statement has saved my tail several times in deposition cases.
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.
I respectfully disagree with this. Writing, "No new orders," means exactly that and nothing more. In fact, the notification part of our computer charting gives two choices--"Orders received," and, "No new orders." These options ought to be taken at face value.
It is context that invests the phrase, "No new orders," with anything other than its surface meaning. If, in looking at the big picture, it appears there should have been new orders (because the patient went downhill and the nurse had to keep calling back), it is the situation that casts a shadow over the lack of action taken, not the phrase itself. Conversely, if all is well, it can be inferred that "No new orders" was an appropriate response.
The phrase alone means only what it says. The results that follow determine whether the choice was the correct one or not.
It's not a "dig"...it's the end result of my process of letting the MD know of a change in the patient's condition. Sometimes I don't want a new order, either, it's just something that he should know. Sometimes I DO want something, and don't get it. The phrase "no new orders received" is written no matter what. Makes it clearer to the next nurse what the outcome of notifying the MD was. That is all.
I always state "orders recieved" or "no new orders". I am stating an outcome fact of my phone call. Nothing more.
Tait
Agreed. I'm not implying anything when I write "no new orders". I also write "new orders received", or "see new orders" when I DO get orders. There's no opinion involved. Just stating the facts. If I were of the opinion that orders were needed and I didn't get any, I would pursue the matter up the chain until I felt the issue was addressed appropriately.
How does it cover you to say "repeated and verified"? The doc can still deny the whole thing.
The doctor can deny anything. But I agree with penguin, if I write "no orders received" it's because well, no orders were received. Period. Not that I disagree. I've often called because the family insisted, knowing the MD wouldn't order anything. I don't want it said later on that the doctor did order something and I forgot or chose to ignore it. Sure the doctor can say they ordered something, just like they can deny a verbal order, but then they're questioning my integrity and I'd rather have complete charting documenting my side when it comes down to the she said/she said showdown.
I usually document no new orders received just to verify that none were received, versus one being verbalized and never properly written or acted on. In my opinion, not charting that leaves open the possibility that you could be accused of taking a verbal order then never transcribing it.
If I were of the opinion that orders were needed and I didn't get any, I would pursue the matter up the chain until I felt the issue was addressed appropriately.
Absolutely. I once had a patient with an extremely high BP that the on-call did not feel needed to be addressed. I was rather upset and spoke with my nurse manager the next day about it. She asked why I didn't directly page the service's attending. It was a real ah-ha moment for me that that was even an option. Luckily, it hasn't since been warranted.
I'm more fond of the phrase-"no change in current orders"- it indicates that we are doing SOMETHING- and the doctor feels it is the best option at this time. "No orders given" seem to contradict the 2-3 pages of PRNs and instructions I have already. "continue to monitor" seems wrong since a lot of the time I'm not just monitoring- I am treating but there may be a change in labs, LOC VS that may indicate a change in the patients condition- but may not warrent a change in therapy unless it continues or gets worse.
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.
this is how VO/TO's work at my hospital.
it's a pretty good system. i'll listen to the orders and either put doc on speaker phone or say "can you please hold and repeat that to another nurse?" and then both of us sign the order. the docs are used to it and they know its the rules. it's not bc i am a LPN, it's for all of us nurses. that way we have a witness to the order and another set of ears to verify it that it is the right order, the right patient.
cardiacRN2006, ADN, RN
4,106 Posts
This is standard practice in any ICU. You're right in that we have a lot more leeway..I can't tell you how many times I say "I've already started that" or "I've already done that" when I call important info to the Drs...
Of course, you know who to trust and who not to....