Doc, over at ramblings of a disorganized mind believes he has the answer:
I always find it funny when the nurses calls 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 cover your ass 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. It should by OK to state "Dr Smith notified of _____". The extra emphasis of "no new orders received" seems somehow, in the mind of the nurse, to place an exclamation point on the notification. I'm not sure how a jury would quantify the importance of one statement over another. Personally, I don't think it matters.
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. With that said, maybe I should start documenting, "blood pressure medicine given 15 minutes late", or "IV pool was beeping during my evaluation and no one responded". Or "nursing staff won't walk the patient six times a day as requested." "Or patient lying in a pool of stool during my evaluation." Or how about documenting "nursing assessment lacks substance." Or "nursing staff doesn't seem to understand side effects of patient's current treatment." Or "nursing staff failed to notify drop of UOP from 80cc/hour to 40 cc/hour."
Of course I wouldn't write any of that since I find the whole idea of writing "no new orders" nothing more than a perceived form of CYA in this legal driven medicine we practice.
I've had a few cases of critical radiology reports signed out as Dr Happy notified at the time of this dictation, when in fact I was never notified, or I was gone and my partner was notified. The medical chart is nothing more than a giant invoice and legal document. It has long since left this world as a documentation of meaningful medical information. If I spent my entire day worrying about "no new orders" I would never be able to take care of patients who actually needed them.
32 Outbursts:
This is derived from the old nursing "SOAP" note...Subjective data, objective data, assessment (what's wrong), and plan. "No new orders" is the plan or "continue to monitor" or whatever.
Of course, no new orders is the nursing equivalent of the double-bird. I think some nurses aren't aware that this is a cuss, however. I'm trying to spread the word, but there is only one Nurse K.
Maybe I wasn't clear (or maybe you weren't)....I never write "no new orders" in the order section. I do write it in the nursing documentation section, for instance when I've documented an abnormal lab value or VS, notified the MD and received no new orders. If written in the order section it would be out of context...why would anyone do that unless they're documenting abnormal values in the order section as well? I also stated that documenting 'no new orders' is not intended to be CYA, it just has that side effect, though I'm sure some nurses use it solely as CYA.
Happy, you are a very inconsistent person.
I read your blog on the subject Nurse K. I just checked with a few folks, and it's not the double-bird here, (yet). If put in a really shitty situation due to MD failure to launch, I'd probably revert to my most exquisitely cruel old corporate ways of retaliation. These things must be handled d e l i c a t e l y.
-SCNS
You seriously underestimate me Nurse K. You have no idea how much.
-SCNS
We use computer order entry, and the nurse will enter the order for the physician often, and then the physician can sign on the computer and sign off the order. Saves some time and the physician can sign off on many orders at once. Writing "no new orders" to me also clarifies that I wasn't given orders over the phone and they simply didn't get written or put in the computer.
I only mind "no new orders" when they write it on an Order sheet, so I have to sign, date, and time it later! That unsigned "order" may get me suspended for incomplete records.
Nurses, keep it it in the nurses notes.
Well, I've charted "no new orders" but I consider it a statement of fact rather than a passive-aggressive gotcha. And I chart that in my own notes, although one hospital's policy was that it be written on the order sheet, a policy I ignored. I guess it's more force of habit than anything. When I call a physician for a change in patient status, I follow up my descriptive note with "doc notified - see orders" or "doc notified - no new orders." If it's an issue I'll quit doing it. I don't care, less words for me to type.
And DT - my apologies for the unsolicited advice but if you are working a shift you consider dangerously short-staffed, write 'em up, each and every time. After 18 years I have no patience for admin.'s lame-ass excuses of why we have to do the work of 2 people while they shmooze during their catered lunch meetings. There's staff out there, they just don't want to pay the overtime, bonus pay, or agency pay. No one should work 12+ hours without a break, and that you do it speaks to your dedication, but you can't keep that up. We have to take care of and protect ourselves by demanding safe staffing levels. It's admin.'s responsiblity to staff safely, and they should be accountable for that.
First and foremost, the original issue: Our teaching hospital (read: lots of new residents) uses computer charting with software that has a little section: MD Calls: Orders Received (or) No Orders Received. I would never write that as an order. That's stupid, makes nursing look like they are being ugly. Belongs in the nursing notes, and simply to document whether or not something is a completed issue.
I too have gone up the food chain when needed, and my very favorite was having to pull the head of the department out of a surgery to address an issue. Lots of fun, I can tell you. However, it needed to be done, and that's part of my job. I do not, however, document something like that in the orders section. Why not just hand the front door key to whatever attorney may be looking at this later? Again, foolishness.
We are all a team. Period. In point of fact, if we are frequently up to the elbows in poop or blood or vomit, we should all at least try to act like family. We may not LIKE some members of the family, but if it's life and death - and it often is - we need to keep the childishness and passive aggression out of it.
Of course, that's just one nurse's point of view :)
Sure it's a CYA. So what? Patient safety is a nursing issue. So it goes like this: A change/problem develops. Nurse notifies doctor. Doctor judges issue to be insignificant. (And we all know doctors are *never* wrong!) Nurse is concerned that new finding is significant. Nurse has no authority to fix problem. Nurse feels frustrated/helpless/concerned. Little problem has potential to become big problem. Nurse writes "no orders received." BFD. (Big Fucking Dealio.)
Guess what? The resolution is simple: Communication. Suppose the nurse's concern is respectfully acknowledged (rather than, say, snickered at or brushed off) and the physician takes 45 seconds out of his/her busy day to put the finding into context (give information which the nurse may not have/know), then perhaps the nurse will understand the physician's reasoning and not have to worry him/herself sick that s/he is not doing something to "fix" the problem. Better communication also gives the nurse the opportunity to make his/her case for why s/he believes that some action needs to be taken. When nurses and doctors communicate, everybody wins.
Personally, I have never written those words. If I discover something that, based on my knowledge, experience and gut I consider significant enough to report and worthy of some action, and if the intern and resident blow me off and/or can't give me a damn good reason why what I think is important is, in fact, not important, then I call the fellow. If the fellow won't listen, then I call the Attending, even if it's two a.m. I have taken my concerns to the fellow many times. I have only had to go as far as the Attending a handful of times. Guess who ends up eating crow. But if you're going down this road, be DAMN sure you know what you're talking about.
Finally, Happy, if you are examining a patient who is lying in a puddle of stool, that's on YOU, brother. Either 1) IMMEDIATELY find someone to take care of it BEFORE you examine the patient or 2) Clean it up your god damned self. If you are examining someone lying in poo you are heaping indignity upon indignity. Shame on you. As for the rest of that paragraph, you are indulging in logical fallacies (tu quoque and weak analogy) which not only doesn't make sense here (a beeping IV is not like deciding not to treat a K+ of 6.7), but, I thought, was beneath you. But then again I didn't take you for the kind of guy who would examine a patient lying in a puddle of shit.
Oh Happy, now you're just being a "poop". You started out being honest (and correct) and then got angry.
It's not all that evil. "Spoke with Dr. Happy. No new orders received" This just states that I let you know. Oncoming nurse will say to me, OK you notified Dr. Happy. Assumption by all is that you are aware and don't feel it necessary to act... right now. Fine.
I've documented because noting changes/taking action is part of my job. You say yourself that you waste time covering your butt daily. Gotta do it.
Unfortunately nobody wants to be "taken out" by someone else's issues. Thing is, part of what we do is to watch you for our patient and our own safety. If I do/don't do something off of your orders/lack of -- I am liable too. I won't sit and wait for you too long.
-SCNS
You handle things delicately and your patient will be delicately dead. Of course you don't just chart "no new orders" and let your patient die of septic shock, you go up the chain of command, which is different depending on where you work. Sometimes this involves a fair amount of really quick problem-solving to get around a layzee doc or a passive-aggressive one. It's not like "corporate won't approve my travel expenses for dinners with clients"-type problem solving.
For all I know, I called ya and you were sitting on your sofa all snuggly with the dogs watching Sports Center (in a trance)... I know you weren't listening.
-SCNS
PS:
"God knows enough doctors have no problem humiliating nurses when they have the chance. The revenge part I don't mind but the blatant stupidity of it annoys me."
I have watched that BS on BOTH SIDES for over twenty years. Starting with RN's humiliating interns/residents for passive-aggressive BS reasons get even reasons (usually from some slight by another docs years ago) and the visa-versa with attendings. NONE OF IT IS APPROPRIATE ON EITHER SIDE. IT SHOULD BOTHER YOU FROM WHOMEVER IT COMES FROM. If you weren't so passive-aggressive and immature you would get it. Nurses shouldn't put up with that crap nor doctors. It stains both of our professions. GET IT?
Happy, you are jumping to conclusions. After documenting notifying an MD of a significant value, it is natural to also document the outcome of the notification. This is what all nursing students are trained to do. It may also serve as a CYA, but this is just a side effect, not an intended outcome....although I'm sure there's exceptions to that rule.
Hate to point it out to you, but this post of yours continues your jackass rep. So you say all these (supposedly) great things about nurses in other posts...and follow up with a post like this. And one is expected to believe that you appreciate nurses? Hmmm.
No order today either.. hope that makes nurses happy too.
DreamingTree said,"We're asked to do more & more with less and less staff. I realize that you were most likely being a smart ass with your comments -- they hit a sore spot. Most nurses want to do a good job. Give us safe staffing levels and we will."
Honey, you're preaching to the choir...but if you're given a certain amount of work, you HAVE to get it done. This is what physicians do. And since nurses can make almost as much as primary physicians these days, I doubt their will be much sympathy from the doctors.
Anon: "Honey, you're preaching to the choir...but if you're given a certain amount of work, you HAVE to get it done. This is what physicians do. And since nurses can make almost as much as primary physicians these days, I doubt their will be much sympathy from the doctors."
My comment was in response to what Happy wrote, and I realize that most physicians understand the dilemma we are all in. HOWEVER, I make nowhere near as much money as a physician, nor do I expect to. Besides, money isn't the issue here. I can physically only do as much as time will allow. On busy, short-staffed days, I already stay late to chart (allowing me to provide constant care to my patients). I rarely get a lunch break, or a bathroom break. So, what type of magic would you suggest I perform to enable me to get more done in my day? It isn't a matter of work ethic or efficiency -- there are only so many minutes in a day. And, let me repeat, when I have patient care to provide, I leave my charting until I've reported off to the next shift. Other than charting, my duties are all patient care oriented. I'm open to suggestions.
Thanks for the advice, michele. I'm thankful to work with some wonderful nurses who help without being asked. We're fighting for what is right (with the support of the medical staff). This is a second career for me, so I have many options. With that said, I like a good fight, so I'll be sticking around to help get some change at this hospital.
I agree, Dr. happy, it belongs in the progress notes and not in the orders.
I suspect that the Foley advocate would not write "no new orders" in the order section, if you gave her orders for a u/a & c&s.
I disagree liz. writing "no orders" in the order section is not an order. It is an observation. I should be under no obligation to sign off that order, since I didn't give an order for no orders.
When I say thank you for notifiying me, should you write an order that says, "Dr Happy said thank you"
I talk with nurses all day long at the bed side. We talk about patient care issues. They ask me questions. I ask them questions. Rarely does any of this discussion make it into the chart. Because it is not perceived as important for legal reasons. If you ask me for a foley and I say no, I never see an order that says "Dr Happy says no to foley".
The reason "no new orders received" makes it into an order sheet is for CYA. It serves no other purpose. I'm saying that's fine. But you don't need it in the order section. You can place it in the nursing documentation section. Certainly a lawyer will find it there.
Feel free to write what ever you want in the nursing documentation, including "no orders given" if it makes you feel better.
You admitted it's CYA, why are you mad at me? I'm just calling it what it is.
... Happy? It's doc'd in the computer, in assessment notes (nursing) next to the corresponding assessment info. Would not write it in the MD order form (not an order...).
I think you got that from Dr. Parker's note, a reminder not to accidentally put a note on the MD order form...
-SCNS
Catharine get off your high horse. We all know EXACTLY what you were backhandedly trying to say. Take your passive-aggressive BS and shove it.
"Patient safety is a nursing issue"
Ahem just how is it NOT also a doctor issue. Get a clue.
Again, Happy, I have to ask...ARE YOU A REAL PHYC...ummm DOCTOR??!?!?!
Cause no Real Doctor I know give's a Rat's behind about Nursing Notes... They'll tell you anything they thinks important... Only Nursing Notes I used to look at were this hot Ukranian's named Tatiana, and thats only cause her handwriting reminded me of my girlfriend from the 6th grade... Seriously, I don't even read other Doctor's notes, like you said, 99% of its just computer generated Boiler Plate for the Insurance/QU Nazis... And don't ever bother reading my "Notes"...I intentionally make it look like a cross between A-fib and slow V tach... Nostradumas's stuff is more clear... If it ever goes to court... they can't even proove who wrote it...
Frank
By the way, I think the stupidity of writing "no new orders" *in the physician order section* is self-evident. This is the kind of thing that gives nursing a bad name. I think it is meant as a "dig" at the doctor. God knows enough doctors have no problem humiliating nurses when they have the chance. The revenge part I don't mind but the blatant stupidity of it annoys me.
["Patient safety is a nursing issue"
Ahem just how is it NOT also a doctor issue. Get a clue.]
I'm sorry, I don't recall saying that patient safety is "NOT also a doctor issue."
Congratulations. You have a keen grasp of the obvious.
Hmmm...RN here...nurses are taught in school to write, "Dr. Blank notified of blah, blah, blah. No new orders received" in order to show that 1)yes I contacted the physician, and 2) no orders were received (I did not just forget to write them down), BUT this is supposed to be written in the nurse's notes, not the ORDERS!!! I have never heard of a facility where it is supposed to be written in the orders section. I think you are right; the nurses who do this to you are flipping you off on paper.
SCNS. Speaking with me doesn't say anything to anyone. You could have called to talk to me about the weather. If you need to write that I was notified of the BP of 89/56, that's all you need to write.
And that's my point.
Nurse K underestimates everybody except for herself. Please stop replying to this clown.
Well, of course I would write that I notified you of the BP. The "no new orders" is necessary sometimes too. Saves the question/maybe another call for same from concerned oncoming. And things got this way long before I jumped into your pool ya know.
Come on. You are being a "poop"
-SCNS
Wow, I can't believe you don't understand why a nurse writes "No new orders". If something goes wrong with the pt later, the Dr could simply state he was never notified of situation. Its very simple: CYA!! Thanks
I'm guilty of using the "no new orders" in the past, because that is what we were taught to do. After reading one of the blogs (Nurse K's? can't remember...), I quit using that line. I honestly had never considered the negative interpretation of such a simple statement. And, I have to agree that it is a CYA move.
You certainly could start documenting poor nursing care, and then we could start documenting poor staffing. As I pointed out to one of our doctors, I understand the importance of basic patient care (turning, ambulating, bathing, etc.), but most days I'm struggling to stay on top of the higher priority tasks (Why did you increase the bp med when SBP = 100? Pt X has developed chest pain. Pt Y has a critically low hgb. Pt Z can't maintain a sat above 85%. You get the point...). We're asked to do more & more with less and less staff. I realize that you were most likely being a smart ass with your comments -- they hit a sore spot. Most nurses want to do a good job. Give us safe staffing levels and we will.
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