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

Nurses   (9,307 Views 48 Comments)
by Anxious Patient Anxious Patient (Member) Member

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2 views from 2 doctors

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.

More from this doctor:

http://jrh-roadm.blogspot.com/2009/06/two-thoughts.html

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.

More from this doctor:

http://thehappyhospitalist.blogspot.com/2009/07/why-do-nurses-write-no-new-orders.html

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PAERRN20 has 3 years experience and specializes in ER.

660 Posts; 7,068 Profile Views

I agree. CYA CYA CYA!!! I can't stress this enough. If things head south, at least you have documented you alerted the MD and did not get any orders. I chart no new ordered received fairly often.

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shellsgogreen specializes in ICU.

328 Posts; 4,195 Profile Views

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.

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220 Posts; 3,547 Profile Views

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.

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3 Followers; 36,918 Posts; 97,851 Profile Views

I was told it was to cover yourself emphasizing that you made the report and the doctor didn't want to give any orders. That's all.

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cardiacRN2006 is a ADN, RN and specializes in Cardiac.

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Whahhh. Too bad if Drs don't like it. It's really my job to take care of the pt, and if orders aren't warrented then fine.

But I'm not going to end up in a courtroom because a Dr says something like, "I wasn't made aware it was THAT bad" or "the nurse didn't say THAT"

Nope.

I don't just document that no orders received, but I document the whole dang conversation. I'll document when I've paged the Dr and got no call back. I'll document when the Dr is on the unit and I've updated them on the status.

And if they don't like it then too damn bad!

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cardiacRN2006 is a ADN, RN and specializes in Cardiac.

4,105 Posts; 16,822 Profile Views

i don't write no new orders received, i usually write "no intervention indicated at this time" .

what if interventions are indicated, and the dr didn't give you orders?

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Lorie P. specializes in Med/Surge, Private Duty Peds.

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cya, cya, cya.... i usually put " no new orders received, continue to monitor pt's status" of course i chart why the doc was called and all info i gave to him/her. from a past experience i had to call an on call doc 3 x about a pt that had a major change in status and the pt expired right at shift change. i had over 3 pg of notes documenting everything, which is what saved me and the others per risk mgmt.

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17 Articles; 4,167 Posts; 31,407 Profile Views

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.

i understand what you're trying to do when you write, "no intervention indicated at this time," but that wording is open to interpretation and could leave you vulnerable. no intervention indicated? by what standard? who made that judgment? does that mean the doc didn't feel any new orders were warranted or that the patient's condition and circumstances didn't require any action or that you, the nurse, didn't see the need for new orders?

the difficulty with this particular phrase is that if there is anything the least bit questionable, it could be viewed that an intervention was indicated, but you or the doc or both of you dropped the ball.

writing, "no new orders," refers specifically to the doc and his or her responsibility. it makes no value judgment about whether orders were warranted or should have been made. it simply states the fact that there were no new orders issued. it may seem unnecessary, but especially in questionable circumstances, it can document the number of times a doc was called before action was taken.

if everything goes well, "no new orders," is just a formality that verifies the obvious--obvious, because there aren't any orders to write. when things are coming unglued, it's a way of recording the choice of the doc to defer or delay action after the nurse has made proper notification. it's also a line of demarcation between inaction (which is the appropriate choice many times) and action. if you finally get orders after several requests, "no new orders," makes it clear which call elicited an active response. otherwise, it could look like the orders you received after the third call were a response to an earlier entry.

"no new orders" can also be viewed as the nurse's way of saying, "i didn't forget to write orders which were entered in the computer but omitted here in the chart."

Edited by rn/writer

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Mommy_of_3_in_AL..RN specializes in MICU, SICU, CRRT,.

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I always make note that orders were or were not received, anytime i speak with a doc regarding change of status, or even if the doc was a bedside with the patient. Its a definite CYA thing. I also chart what time i paged/called the doc, what time they called back, what info was given to them, and their response. In some situations, the doc will request that i notify a different doc of the situation, and i chart that too..basically every correspondence that takes place is charted. If a doc comes to the bedisde, i chart "Dr. X at bedside, assessed patient. No new orders received" or whatever statement applies. Its also a way to acknowdge that i saw and spoke with the doc, and that i reviewed the chart, noting the prescence or absence of orders, so it cant be said that i let those orders slide later on.

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Jenifer819 has 6 years experience and specializes in OR, Peds: ED, float pool; ED, PACU.

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I will write 'no new orders written' in nursing notes for a few reasons 1) to let the RN's know I am aware of all doctor's orders. I also always write...will continue to monitor. It is CYA. I never thought that it was a dig on the MD's.. 2).just documenting that I have spoken with MD, and no new orders written at this time.

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282 Posts; 6,484 Profile Views

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".

Edited by Penguin67

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