Writing Orders

[Ponyboy]

Here's a quick poll:
As a third year medical student, how much authority did you have when it came to writing orders? Could you write your own orders for your patients without having them co-signed? Did all of your orders need to be co-signed? Or could they have been simply "discussed with Dr. So and So"?
Just curious.

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[GreatPumpkin]

We had a computer system that allowed the student to put in orders but would not be "release" until co-signed by a resident or attending.

I am sure most places have something similar to this because it would be malpractice to let a student give certain orders without cosign.

 

[dr.evil]

We had the freedom to write the orders prior to rounds but the orders would not be carried out unless cosigned by a doc. Sometimes, however, the order got carried out prior to approval by the M.D. but this was rare.

 

[denise]

I was the same way; wrote orders on pre-rounds, then they were taken off during rounds when the attending signed. That is, if he agreed with them all When I was a 4th year, there were plenty times orders were done before the attending was there. Especially, if the nurses saw how the attending and I interacted. One time I went to wean a pt of the vent, the O2 sat alarm went off when the ICU Dr walked in. He said, "how did she get on CPAP." I spoke up, he just replied "I guess she is not ready to be off". I was very nervous!!! It was a great rotation. If you show interest, and suggest orders, you will be surprised what you can do.

For some reason the students under me now do nothing close to orders?????

 

[pags]

Damn, yer good...

 

[wvshootr]

At our hospital, I commonly write for orders that I have either been told to by the other residents, or simple ones that I come up with and run by the residents. By writing them as V.O. orders (verbal orders) per Dr. so-and-so on the chart. I can just sign my name to them. It's the same as if the doc would call the nurse and order it, she would write the same thing in the chart to document. By doing this, i can save the intern a lot of scut time. Of course I'd never brave writing an order without at least approving it with the resident. I'd hate to even think what would happen if I were caught doing that. Most attendings don't even check the order sheet, and simply just take the resident's word for it.

 

[Pinky]

At the community hospital I recently rotated through as a sub-I, I wrote orders without having to have them cosigned. As long as I signed my name with my four digit pager number, my orders were carried out. Often, I was writing for morphine, demerol, in addition to expensive tests (PET, MRI) without being questioned. The other sub-I and I reflected on the idea that if these charts were ever reviewed in a malpractice lawsuit, the fact that uncosigned med student orders were being carried out would not be good for the hospital.

 

[Whisker Barrel Cortex]

wvshootr,

Although I haven't seen the laws on this topic myself, I have been told by several different sources that medical students do not have the authority to write verbal orders from residents or attendings. Nurses do have this authority. Of course, two of the people that told me this are nurses, so I can't be sure of its accuracy. I think its a pretty stupid rule if it is true.

 

[Firebird]

Originally posted by wvshootr:
•At our hospital, I commonly write for orders that I have either been told to by the other residents, or simple ones that I come up with and run by the residents. By writing them as V.O. orders (verbal orders) per Dr. so-and-so on the chart. I can just sign my name to them. It's the same as if the doc would call the nurse and order it, she would write the same thing in the chart to document. By doing this, i can save the intern a lot of scut time. Of course I'd never brave writing an order without at least approving it with the resident. I'd hate to even think what would happen if I were caught doing that. Most attendings don't even check the order sheet, and simply just take the resident's word for it.•••

How disappointing! I see a new person on here from WV and it turns out you're from WVU. Since I'm an MU undergrad, our schools are mortal enemies and I suppose we are not allowed to talk on here...

...ok, so I'm just kidding...

How's WVU's med school compared with Marshall's?

 

[RBorhani]

If your hospital is charging the patient under Medicare (99.9% of our patients), then only a registered nurse is authorized to take verbal orders from a doctor. When I was a med student one of the attendings told me to compare myself to the hospital janitor if I ever had questions about the Medicare laws?i.e. ask yourself can a resident give verbal orders to a janitor?if the answer is NO then a med student cant take verbal orders either.

Also medical students are not authorized to write the physical exam findings, differentials, lab values, or diagnosis and plan on the chart. They can and should do all these but just they cant write them in the chart. This is a pain in the a.. in the ED, when med students see patients and residents have to write the information down on the chart.. Medicare law limits medical students to PMH, ROS, Social, FH, Meds, and Allergies... Stupid but that?s the law... Our hospital takes these laws seriously as the hospitals will get big time fines if they are ever caught not following them...

Smile and just play the game? and in two short years you will be bitching about having to write too many orders <img src="graemlins/pity.gif" border="0" alt="[Pity]" />

 

[Billie]

Originally posted by RBorhani:
•
Also medical students are not authorized to write the physical exam findings, differentials, lab values, or diagnosis and plan on the chart. They can and should do all these but just they cant write them in the chart. This is a pain in the a.. in the ED, when med students see patients and residents have to write the information down on the chart.. Medicare law limits medical students to PMH, ROS, Social, FH, Meds, and Allergies... Stupid but that's the law... Our hospital takes these laws seriously as the hospitals will get big time fines if they are ever caught not following them...

•••

This is too true. When I started rotations last year as an MS-III, everyone in my class was sent this pamphlet (from Medicare) about how we were NOT to write in the charts. If the doc/hospital wanted to aid in our training, then we could make up a separate "student chart" and write everything in that, and the doc would review it with us. But I found that most docs did not have time to look over 2 separate charts (ours and the "real" one) and I personally never created a separate chart. Most all I ever did was go see the patient first, write my finding out on a blank piece of paper, then report back to the doc who then went to see the patient, and then he wrote in the official chart. My piece of paper then was trashed, even if it was the very same findings.

I agree this is a big pain in the a&& as I am approaching graduation in 4 months, and worry that now as an Intern, I will not be very good at writing orders, charting, etc, as I have not done it!

 

[tedsadoc2002]

About unlicensed personnel writing verbal orders from residents or attendings, in New York (and I believe in many other states) is against the law. The reason I say this is because I was a registered nurse in NY and only we could write the verbal order that the physicians gave. I believe there are even some states where the LPN/LVN (licensed practical or vocational nurse) is not allowed to write verbal orderes and he/she IS a licensed professional. In order to protect yourself and your patients, please always refer (when in doubt) to the hospital's policy and procedure manual which should be on every unit. If it is in the P and P, then it is considered approved by the hospital and you're okay.

Discretion will protect you, and understanding will guard you. Proverbs 2:11.

 

[Scrofula]

Originally posted by RBorhani:
•If your hospital is charging the patient under Medicare (99.9% of our patients), then only a registered nurse is authorized to take verbal orders from a doctor. When I was a med student one of the attendings told me to compare myself to the hospital janitor if I ever had questions about the Medicare laws&#8230;i.e. ask yourself can a resident give verbal orders to a janitor&#8230;if the answer is NO then a med student cant take verbal orders either.

Also medical students are not authorized to write the physical exam findings, differentials, lab values, or diagnosis and plan on the chart. They can and should do all these but just they cant write them in the chart. This is a pain in the a.. in the ED, when med students see patients and residents have to write the information down on the chart.. Medicare law limits medical students to PMH, ROS, Social, FH, Meds, and Allergies... Stupid but that's the law... Our hospital takes these laws seriously as the hospitals will get big time fines if they are ever caught not following them...

Smile and just play the game&#8230; and in two short years you will be bitching about having to write too many orders <img src="graemlins/pity.gif" border="0" alt="[Pity]" /> •••


Wow that sucks. At my school we write the whole H&P, including plan, in the patient's chart. From looking through many many charts I've found that the medical students often have the most detailed notes, so I don't understand why they would be disallowed. Anyhow, it's not like anyone is going to look at my plan and take it more seriously than a resident's or attending's!

Orders are computerized and require vrification before being forwarded to the lab or pharmacy. However, during my sub-I I gave a verbal order (without first speaking with my resident) to a nurse to give my pt. insulin STAT--I don't think she would have followed my order if she didn't think it was reasonable.

 

[Neurogirl]

Ordering the nurse to give insulin may have been reasonable, but it was NOT legal (the nurse should have known this). For those of you who think you're writing orders without cosigners, I can assure you that at some point the orders ARE being cosigned by the attending (either when you're not around, or later, in medical records). This should not be allowed. By writing an order, you are utilizing the license of your superivising physician and that physician will be held responsible for ANY AND ALL orders you execute.

Regarding allowing students to chart, some clarification is needed. In the ED, students are NOT allowed to chart, however, on the wards, they may chart if the attending also examines the patient and writes an addendum to the note. Our attendings usually write "patient examined and case discussed with student", or sometimes they'll simply write "seen and agree". If they don't agree with a particular physical finding, they'll draw a line through the student note and write their own finding. I don't know why the rules are different for the ED but am sure that they are. When the laws changed (a few years ago) there was no debate regarding student charting in the ED. It would not be allowed. However, there was much debate among attendings about the legal aspects of student charting on the wards. It was finally determined that the aforementioned proceedures would allow us to be in compliance with the new medicare laws. When I rotated at different hospitals (in different states) similar approaches were utilized.

 

[Pinky]

What should be done (i.e. what is legal) is often different from what is done in everyday practice. At the community hospital I worked at, student orders were carried out without being co-signed. To the clerk who was entering orders into the computer, all signatures with pager numbers looked the same. There were so many different residents and attendings who were signing orders so they never really knew who was signing orders. As long as a name and a pager number were included on the order, the order was carried out. My written orders were even carried out by the pharmacy. While this is not legal and should not be done, it was done and continues to be done.

 

[drusso]

Actually writing "seen and agree" or similar comments is no longer acceptable by the Agency for Medicare and Medicaid (or whatever they call themselves now). As someone else pointed out, by the strictest interpretation of medicare regulations, medical students are limited to only collecting certain kinds of patient information (ROS, PMH, Social, Family Hx, etc). There is still a lot of controversy about this though because most medical educators feel that not having students write in the charts is seriously shortchanging their education and creating duplicate "student charts" is wasteful and confusing.

One way around this regulation is to use medical students as scribes; that is, to have students begin each note, "Scribing for Dr. So-and-so" and sign each note, "Joe Blow, MS-4, Scribe for Dr. So-and so." The problem is that when notes are scribed, they become the "actual words and observations" of the attending physician and can be entered into testimony as such in a court of law. You can imagine that some attendings are a little hesitant to let their malpractice premiums ride on the observations of a third-year medical student.

There is a huge disparity in how these regulations are being enforced. In general, private facilities are stricter than public/county ones. However, I suspect it will only take a few malpractice cases where the plaintiff's attorney refers to medical students' scribed notes as actual physician observations to force hospitals to stop letting students chart.

This is really an issue that medical student organizations such as AMSA, MS-AMA, and SOMA should be taking up as it directly affects medical education.

 

[Neurogirl]

Pinky,

If you know what you're doing is illegal, why would you continue to do it?

 

[Pinky]

It's something that we're expected to do. As sub-I's, we're supposed to function as interns. We carry as many patients as the interns do and cross-cover patients for the other sub-I's like the interns do while on call. Interns write their own orders and so we too write our own orders. Technically, the senior residents are supposed to co-sign our orders, but this only happens ~50% of the time. And usually the orders get cosigned later in the day after the order has already been carried out.

There is no malicious intent involved with the fourth year med students writing orders. Most of the orders that we write have been discussed with the senior resident or the attending (i.e. we are just writing down what we've been told or what was written by the attendings in their assessment/plans). Otherwise, the orders that we come up with on our own are usually basic like "BMP, CBC in AM" or nursing orders (e.g. "daily weights, strict I/Os, etc.) So, patient care is not being jeopardized in any way.

So why do I do it despite the questionable legality? Because I'm doing a 4 week rotation at a hospital where this is the practice. As long as patient care is not being jeopardized, I'll continue to do what my superiors tell me to do.

 

[drusso]

•••quote:•••Originally posted by Pinky:
•

So why do I do it despite the questionable legality? Because I'm doing a 4 week rotation at a hospital where this is the practice. As long as patient care is not being jeopardized, I'll continue to do what my superiors tell me to do.•••••Not to make too much of a big deal about this, but it does raise interesting ethical issues. You (and me for that matter) are knowingly breaking the law. Do you think that your rationale would be defensable in court? Under what circumstances is permissable to "just follow orders" of your superiors? Again, not to overstate the issue, but weren't the Nazi doctors also "just following orders?"