writing telephone orders

[nurse4lyfe37]

I have a question ...ethical..in the state of Wyoming. I get to work and in report am told a resident was sent to the hospital 2 hours prior. I call the hospital an hour later to check the status and am told the resident was admitted to icu. later, the nurse manager informs me that the resident passed away at the hospital. I am told to write a physicians telephone order stating admit resident to intensive care with a diagnosis of.....(call the hospital to get the diagnosis. ) I call the hospital and am told they can't tell me the diagnosis due to hippa. so at this point I don't feel comfortable writng the order. how can I legally write a telephone order without speaking to a physician anyway. am I right in my hesitation or is it legal to do this. every time a resident is admitted, they want me to write this type of physicians telephone order without talking to a physician. please advise thank you.

[LadyFree28, BSN, LPN, RN]

TVOs are written when the MD is aware that the resident was sent out for eval and treatment. Most TVOs are written after the Dr. is aware and gives the OK; per regulations, the TVO ensures the Dr.'s OK for the order; the Dr. Signs the TVO within the acceptable period of time-as long as the Dr is ok, and the order is clear, we write the TVO, and the Dr has to follow up with the signature.

As far as HIPPA from the hospital, LTC is the pts home-that's why they're called "residents"; I have never had or been told that no one couldn't tell why the resident died or had difficulty of finding out what the resident was admitted for.

It's not an ethical issue; that is the process of LTC-much different process in terms of orders and procedures. LTC is one of the highest regulated industries.

[Micki72]

nurse4lyfe37...why would you have to write the order to admit to ICU? If you sent the resident to the hospital, you would write an order to be transferred to the hospital. Once seen by the ED, they determine the next course of treatment. If they think resident needs to be admitted to ICU, they would be responsible to write that order.

[chrisrn24]

You need an order to transfer to the ER. Not to admit to the ICU. That is the hospitals business.

[LadyFree28, BSN, LPN, RN]

My only question is: why didn't you call the doctor?

[nurse4lyfe37]

that's exactly what I thought and what I've always done. I wasn't even there when the resident was transferred to the hospital anyway. im from California and every time a resident was transferred to the hospital, but when they were, in cali, I would do just that, write the order that says transfer resident to er for evaluation and that was the end of it. That is also what I was implying don't even know who made the decision to admit the resident to the and it just doesn't make sense to me to write such an order. I just hope I don't get fired for refusing to write it or something though.

when I first started working there, it took 4 days before someone could produce a policy/procedure manual for me, and everyone I asked for one seemed confused and upset that I wanted to see it. I wonder what their policy says about it. I just think according to the nurse practice act, also according to their telephone order form, I would have to indicate that I read back the order to the physician, and I'd be writing an order, a telephone order, with a physician's name who I have never encountered either by phone or otherwise. the only thing I had to do with the whole situation, was call the hospital to see if the resident was staying or coming back. why didn't the nurse manager herself write the t.o. anyway, since neither of us spoke with the doctor.

[nurse4lyfe37]

why didn't I call the doctor for what? this resident was transferred to the hospital on the prior shift. that nurse should have written an order to transfer the resident to the hospital and that would be the end of it. For what reason would I call the doctor, which doctor? once they were transferred by the prior shift, that's that. Our unit manager spoke with me and said write an order "admit to hospital"...then she left a note for me saying, "write an order 'admit to icu' and include diagnosis...if unsure of diagnosis, call the hospital"...as It was, I had a problem writing a verbal order "admit to hospital" anyway because no doctor told me to and I don't know which doctor made that decision. was it the er doctor? the hospitalist, ? the resident's doctor? So how can I write a telephone order when I don't know from who. the only thing I had to do with the situation was listen to one of the ER nurses tell me the resident was sent to ICU. Isn't there a rule either in nurse practice acts or CMS itself that you cannot write a telephone order without speaking to a physician, although they do it all the time? And I know for sure that there is a rule about indicating diagnoses without a physician, that is completely outside of our scope. I am really really serious about wanting to just make sure of the right thing in case this becomes a coroner case or something subject to investigation.

as far as me calling the doctor, I'm quite sure the resident's doctor is not the one who made the decision to admit the patient.

[LadyFree28, BSN, LPN, RN]

. every time a resident is admitted they want me to write this type of physicians telephone order without talking to a physician. please advise thank you.[/quote']

^This is what I am referring to; why don't you call the doctor when this occurs? You are entitled to nursing practice to exercise good judgement; find out if the doctor wants the pt transferred.

If your experience is in LTC, and are aware of how to perform the proper way to obtain a telephone order, then it behooves you to do so; most facilities do write TVOs ad the Dr. is aware, and as my original post and your follow up post described the prudent way.

You know what to do...

[Esme12, ASN, BSN, RN]

TVOs are written when the MD is aware that the resident was sent out for eval and treatment. Most TVOs are written after the Dr. is aware and gives the OK; per regulations, the TVO ensures the Dr.'s OK for the order; the Dr. Signs the TVO within the acceptable period of time-as long as the Dr is ok, and the order is clear, we write the TVO, and the Dr has to follow up with the signature.

As far as HIPPA from the hospital, LTC is the pts home-that's why they're called "residents"; I have never had or been told that no one couldn't tell why the resident died or had difficulty of finding out what the resident was admitted for.

It's not an ethical issue; that is the process of LTC-much different process in terms of orders and procedures. LTC is one of the highest regulated industries.

I have no idea why they would tell you to write an order to admit to ICU it would be a transfer to hospital order by the nurse who transferred the patient. As far as telling you the cause of death it isn't HIPAA (not HIPPA) because death certificates are public knowledge. The admission diagnosis might be debated as HIPAA by some.

I'd check with the BON

[chrisrn24]

I have no idea why they would tell you to write an order to admit to ICU it would be a transfer to hospital order by the nurse who transferred the patient. As far as telling you the cause of death it isn't HIPAA (not HIPPA) because death certificates are public knowledge. The admission diagnosis might be debated as HIPAA by some.

I'd check with the BON

Exactly.

Typically when a resident has a change in condition I call the doc and tell them what's up and ask if its okay to send them out. When I get the okay I write the order "okay to send to ED for evaluation" or "transfer to ED for evaluation." You get the idea.

[Whispera, MSN, RN]

It seems, even if it's ok to write an order to transfer to ICU, that it's impossible because you don't know which doctor. You can't just use any doctor's name. So, you can't write the order.

I think your facility needs to figure out its policy more clearly.

[LadyFree28, BSN, LPN, RN]

I have no idea why they would tell you to write an order to admit to ICU it would be a transfer to hospital order by the nurse who transferred the patient. As far as telling you the cause of death it isn't HIPAA (not HIPPA) because death certificates are public knowledge. The admission diagnosis might be debated as HIPAA by some. I'd check with the BON

They don't; TVO to eval and treat only; never THAT extensive.

As hat as the HIPAA violation, that was the head scratcher for me because this recently happened to one of residents-he was sent out, coded in ICU and died; the hospital HAS to tell you something in terms of what happened for documentation.