Why do ED docs hate putting in orders?

You can always *update* the attending on the patient's status -- that you are awaiting orders for a Foley, pain meds, etc. I suspect you'll get the orders quickly after that.

those are the Drs we all team up against and ask for orders on every little thing just to **** them off and put them in their place! LOL

ED doctors don't like to be slowed down by having to enter orders in the computer. It's all about throughput and seeing more patients at a time. At my hospital, the ED doctors have pretty much been forced to use the computer. They're not happy of course. They used to be able to have scribes (like me) do all the order entry stuff, but that changed this year. They have to put in for everything, including meds.

Uhh Amen Sista!

Though my comment will apply to Dr's in general. I work in home care..Dr's give me the hardest time sometimes to give me the actual orders I need, written the right way, so that I can do my job..

It blows my mind that I feel I have to explain..."Hey...I really can't do very many things (even apply OTC lotion) unless you write me an order.....

Then their are the ones that insist on making the parents take off and drive over an hour to see the specialist...for silly things they could easily put in electronically.

I also hate when the wording of an order makes it basically useless for what we needed it for...AKA.".May remove NC 02 for 15-20 minutes, during baths: Ok well great now the only way I can remove it is if she is getting a bath...we asked so we could take it off while doing respiratory therapy such as the coffalator or neb tx, as tolerated.

OR Albuterol 0.083%, Neb, Give one vial every 4-6 hours, PRN for SOB....Now, this Dr's Intent that he told us was so we could give them for thinning increased congestion, rhonchi, wheezes, s/s cold, decreased spo2...But becasue he wrote it the way he did, I cant give it unless I can document or witness evidence of SOB...(at oleast according to my agency it works this way.

Lol. Why should I have to explain any of this to a DR...don't they know how HC scripts work yet? They are not real concerned about my license, esp. if they view your request as trivial..and a waste of their busy time.

But...I feel these little things ARE important to us...if they catch us (if it came to a court case or investigation) doing some small things outside of our scope, then that goes to our character...why wouldn't we do that with larger issues too?

They are everywhere. In SNFs the orders have to be very specific but some of the docs don't seem to get it. We spend an extraordinary amount of time writing clarification orders. If the doc or NP writes "Give Lasix 20 mg qd" we have to write a clarification order to read "Give Lasix 20 mg daily." We're converting to EMR next month and the system doesn't allow for 'bad' orders. Can't wait!!

We had a doc who tried to titrate people from 2 to 1 liter of 02 or get rid of it altogether. He'd write "Discontinue all oxygen." I asked him if he wanted my to put a pillow over their face so ALL the oxygen was discontinued. He did have a great sense of humor. He asked me how he should write the order so it didn't look like he had written an order to smother someone. "Discontinue all SUPPLEMENTAL oxygen" worked.

It's not just ED docs. Getting our residents to put in/update orders is like pulling teeth sometimes. Yesterday I had a patient who had been transferred out of the ICU several hours earlier who still had an order for an IA heparin drip. We do not use A-lines on the floor and they are always dc'd prior to the patient's transfer. Is it that hard to click "discontinue" on the order before the patient leaves the unit? Actually, the ICU docs are the ones that should be doing this since it's their order to begin with.

Mostly....they feel it is beneath them, they " Are NOT Secretaries". Second, they now have no one to blame but themselves.

True story. But they have to get used to using the computer.

It depends on the resident, for us, regarding putting orders in. Some of them, it's really bad.

I've had to call the same resident multiple times for different patients before about missing orders... why? They were all fresh, post-op C-sections and had no pain medication orders put into the computer (none, nada, zilch). Ouch.

I guess we are lucky. For the most part, our docs enter all their own orders unless they are tied up in something (it would be kinda bad form to call a MD away from a code so that he can write an order for zofran...that one I'm willing to verbal). We actually have one doc who HATES it when nurses put in VOs under his name. He insists to enter every order himself--not sure if he got burned on this somehow in the past. Anyway, I digress. We have an excellent medical director for our ER, who is very big into using the computers and using CPOE as they were meant to be used. I think the other docs know that nurses would just have to go to him with the names of the docs refusing to put in their own orders and he would have something to say to them.

True story: Had a patient guppy breathing with a tanking bp sinking below 80s systolic and a resident I have never worked with but obviously completely sucks (as far as I could tell in the situation) tried to verbal me 4 mg Morphine (patient weighed about 80lbs too). When I told her there was a computer right behind her and she would have to put it in, she asked me if I was seriously going to make the patient wait till she wrote it and I said right in front of the patient, "yes." (Patients pain associated with respiratory effort). She complained to all of her little girlfriends that I wouldn't take a verbal for morphine on this patient.

Patient DIED like two hours later...after she had written it and after I have given it.

Gosh darn it but a part of me laughed and laughed and laughed. How unrealistic can these little residents get?

[color=#990033]in my personal experience it isn't an "er doc" issue as much as it is a 1st year resident/rotators who can't seem to figure out our super simple charting system and are overwhelmed by their whole "three charts" issue lol. the 2nd and 3rd years have found their groove and aren't spending half of their shift looking up every possible diagnosis and ordering every possible test so that they don't look stupid when rounding w/the attending, so they don't seem to have too much of an issue putting the orders right in. as for the newbies, half of the battle is getting them to order anything before they staff the patient, and i'm sorry but my patient writhing in pain and puking everywhere is not going to wait an hour for you to feel confident enough to staff it, nor do i feel like being yelled at for pain meds you told them you would order when you saw them 45min ago! in those cases i will either be not so subtle in my approach to teach them how this er works, and remind them that even if they are new, they do still have an m.d. at the end of their name and i'm pretty sure ordering the zofran (that i've probably already given while waiting on you, :doh:[color=#990033] lol) will most likely not kill the patient and you would've ended up ordering it anyways when staff asked what you were waiting for! if that doesn't work, i will go to the attending, who luckily are all very laid back and trust our nursing judgement and will back us up. also, in our dem the attendings do not have their own patients in addition to being the staff physician for that area of the dept., except in crazy busy nights where the residents are too slow or can't keep up w/the volume of patients. therefore our staff md's are there solely for supervision, rounds, codes, etc. and they are always willing to help us out by putting an order in the computer, and if they are tied up w/something we will put it in our charting system as a verbal order per whichever doc, and a flagged order will pop up for the physician to click and verify the order, and the patient's chart cannot be d/c'ed from the system until they physically click it off.

as far as orders other than medications, our er nursing staff has a lot of autonomy and we are allowed to order things like foleys/saline locks/labs/certain radiology studies i.e. head ct s/p trauma, portable cxr s/p rsi/line placement/distal extremities etc, as well as certain medications like albuterol/atrovent nebs, tylenol/motrin per protocol for fever, d50 amp for hypoglycemia, etc.

the area that i have the biggest issue with mds doing orders is our cdu/24hr observation unit where it is still paper charting and the patients almost all belong to a specialty service i.e. trauma/ob gyn etc. they generally will end up writing out generic gpu orders before the patient even arrives and then tweak them via verbal order when i keep calling them for things they didn't order, or b/c their idea of pain management is about the same as chinese water torture, like orders for 1-2mg morphine q4 or 6hrs for my kidney stone or pancreatitis patients who could easily handle 4-6mg morphine q3hrs. eventually they go insane from my constant paging and will either order appropriate pain med orders, or if they are being real a-hole's like this one cocky trauma resident we can't stand who treats everyone like a drug seeker, actually says to rns/rts etc that "he's a doctor and we're below him" etc etc, which when he tried that with me, didn't work out so well for him. pt transferred to us for acute chole, pain not controlled by 1-2mg dilaudid at previous facility, states up front that he is a former opiate addict, and is visibly uncomfortable. dr. a-hole totally ignored what the patient was saying during the assessment, and when i was asking for pain meds he starts w/that 1-2mg morphine q6hrs bs. i remind him that pain was not controlled with stronger meds and hx of opiate use, he says "pt is a drug seeker thats all he's getting" regardless of the fact that ultrasound showed significant inflammation/cholecystitis. after giving the first dose of morphine w/no relief, i attempt to reason w/him and explain that i had also had acute chole w/lap chole in the past and explained how painful it was... his reply: "sucks to be the two of you then" and continues to refuse to order anything else for pain. i then went to my cc to ask who i should contact in the chain of command, senior resident or trauma staff, and she says she will talk to him first. so when she calls him he comes huffing and puffing into the er yelling about how he is right and that i should just follow orders etc. well one of our long time er attending's had overheard me talking w/the cc and approached dr. a-hole and stated that if he was so sure he was treating the patient appropriately that she would be more than happy to call the trauma attending for him and he could explain it to them, or that she would personally go assess this patient and if needed, order appropriate pain mgmt and then she would call the trauma attending herself. apparently he realized he wasn't going to get away with his attitude after being confronted by an attending staff physician, and within minutes i get a computerized order from him for 1mg dilaudid ivp prn lol, i guess he figured it would be easier to just let me decide when to give it haha. shortly after this while i had stepped off the unit, he came charging down the hall huffing and puffing again yelling at the tech saying "what, everytime you don't like my orders youre gonna go run to your charge nurse?? bla bla"

in the end my patient was at least somewhat more comfortable, dr. a-hole learned that nurses aren't just there to follow doctors orders and that he will not get away w/his bullying, and i got the satisfaction of getting what i wanted and what was appropriate for the patient.

sorry for the forever long rant, i can't sleep and have drank entirely too much orange pop today and on a sugar high lol. moral of the story is.. if the doctors are giving you a hard time with putting orders in, there is always a way to get it done whether it takes a little muscle or going to their superiors b/c eventually they'll get tired of doing the residents orders and make sure that they are putting them in. lol