Who Can Enter Computerized Orders for Physicians?

Carolyn Buppert, NP, JD

Disclosures

May 24, 2012

Question:

Our doctors want the nurse or clerk to take care of their computer order entry. They give verbal orders or say "You know what I want." Without proof that the physician initiated the order, are we working outside of the nursing scope of practice?

Response from Carolyn Buppert, NP, JD
Attorney, Law Office of Carolyn Buppert P.C., Bethesda, Maryland

Verbal Orders

"You know what I want" is not a verbal order, because the specifics are lacking. When a physician says, "You know what I want" and has not specified the exact nature of an order, an individual who fills in the blanks is practicing medicine without a license. Not only is this outside the scope of nursing practice, it is a criminal act. Moreover, if a patient incurs an injury the nurse could be held liable in a malpractice action because his or her name would be on the order. It is the physician's responsibility to write or state specifically what he or she wants done.

A verbal order -- the mechanism by which nurses and certain other professionals may write orders for physicians -- cannot be given to or taken by a clerk or secretary. Some state laws specify who may receive verbal orders. Most hospital policies designate the classes of staff members who may receive verbal orders. These might include registered nurses, pharmacists, respiratory therapists, and registered dietitians.

If a physician is using the clerk as a "scribe," that is a specific role that must be supported by written policies and other actions. For example:

  • The facility's policies should recognize the use of scribes;

  • The clerk should have a job description that recognizes the unlicensed status and clearly defines the qualifications and extent of the responsibilities as scribe;

  • The clerk should be oriented and trained specifically to the role of scribe; and

  • The clerk's competency as scribe should be assessed and monitored with performance evaluations.

For more on scribes, see a Joint Commission "Frequently Asked Question" on this subject.

For patient safety reasons, the current standard of care is to use verbal orders only in emergency situations when the clinician authorized to give the order is away from the unit or busy with an emergency and unable to write the order personally. Federal law requires that verbal orders be used only infrequently and not for the convenience of the ordering practitioner.[1]

Computerized Physician Order Entry

I understand the practical reasons that a physician might ask a nurse to enter an order using computerized physician order entry (CPOE) and why a nurse might do it. CPOE requires learning a new skill, and some physicians haven't yet learned that skill and don't want to take the time to learn. Nurses and clerks want to help. A nurse certainly can help a physician with order entry and could make the entry if the physician is standing there and reads and affirms the order that has been entered. The input should be made under the physician's log-in name and password. If the nurse is entering an order without the physician present, then the nurse needs to read back the order, spelling drug names and doses, and receive confirmation that the order is correct.

A nurse who complies with a physician's request to make a CPOE is taking a risk. If the nurse is logged in under his or her own password, enters the order, makes a mistake or the physician makes a mistake, and a patient is injured and sues the clinicians and the facility, the physician's defense is probably going to be that he or she didn't make the order or the error. The nurse is going to have a difficult time defending him- or herself.

So, don't do it. Hospitals should have policies addressing this matter, and the policies should support a nurse who refuses to enter an order for a physician. A sample policy is provided in the Table.

Table. Sample Language for CPOE/Verbal Orders Policy[2,3]

Definition of verbal order. A verbal order is an order given by an authorized provider to an authorized recipient while the provider is physically present at the patient’s current location.

Policy: The use of verbal orders in a CPOE environment is to be avoided to the extent compatible with patient safety and care. Routine use of verbal orders in place of CPOE is not acceptable. Verbal orders are not to be used for the convenience of clinicians. However, patient care at times requires the rapid provision and enactment of orders when physicians or other ordering clinicians are otherwise occupied or access to a computer is unavailable or delayed. Authorized providers of verbal orders (ordering clinicians) include ___________. Authorized recipients of verbal orders include _____. An authorized recipient, using his/her discretion to verbally request an order from a provider, assumes the responsibility for accepting a verbal order. Verbal orders that are felt to be inappropriate will be accepted and (if necessary, before being carried out) reviewed with the appropriate individuals, including nursing management and the Medical Chief of Staff. Unlicensed assistive personal are not authorized to take verbal orders.

When the ordering clinician gives a verbal order:
  • All orders must be read back to and verified by the ordering clinician.

  • If the authorized recipient is not physically accessible to a computer, the individual may take the order on paper and read it back to the ordering clinician.

  • If the recipient has written down the order on paper, this is an interim step. The orders are entered into the CPOE, and the paper order is discarded.

  • All alerts must be resolved by the ordering clinician.

  • If the ordering clinician chooses not to stay where the patient is located while the order is entered into the CPOE and the orders trigger alerts, the ordering clinician will be called back by staff to resolve alerts, and the resulting order will be read back to the ordering clinician after alert resolution.

  • Order sets may not be given as verbal orders.

  • All written and CPOE verbal/telephone orders must be authenticated with date, time, signature, and credentials within 48 hours or as required by state regulations.

 

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