Can a Nurse Discontinue a Provider's Order?

Carolyn Buppert, MSN, JD

Disclosures

December 18, 2015

To submit a legal/professional nursing question for future consideration, write to the editor at syox@medscape.net (Include "Ask the Expert" in subject line.)

Question

Which physician orders must be discontinued specifically by the ordering physician or other clinician who is authorized to write orders? For example: A physician writes a telemetry monitoring order. The patient refuses it, so the nurse discontinues it without a physician signature. Or a physician orders vital signs every 2 hours and also has another order for every 8 hours. The nurse discontinues one of these orders without a physician signature. We use an electronic medical record that allows the nurse to "clean up Kardexes" by discontinuing old physician orders without a physician signature for discontinuation. Legally speaking, can any orders be discontinued by a nurse without a physician signature?

 
Carolyn Buppert, MSN, JD
Healthcare attorney

Only a physician or other provider authorized by state law to write physician orders has the legal authority to discontinue a physician order. In no state is a registered nurse authorized to write, or discontinue, physician orders. A nurse who is assigned to "clean up Kardexes" must get a physician to make a decision and enter the discontinuation orders in the patient's record.

To understand the risks to the nurse of discontinuing orders, let's discuss the example of two conflicting orders for vital signs that you have experienced. Let's say a nurse followed the order for vital signs every 8 hours and took vitals at 3:30 p.m. with a plan for another set at 11:30 p.m. The patient was found unresponsive at 10:30 p.m. and pronounced dead. The family sued the hospital.

The family's attorney obtained the medical record and argued that the nurse was negligent because vitals were ordered every 2 hours but not performed every 2 hours. The nurse would argue that there also was an order for vital signs every 8 hours, and the nurse's monitoring was within that time frame. However, it would be very difficult to defend the nurse. The plaintiff's attorney is likely to subpoena the physician, who would testify that he or she ordered vital signs every 2 hours. The plaintiff's attorney will argue that the nurse, faced with two conflicting orders, should have checked with the physician and clarified which order was wanted. The attorney also is very likely to argue that only a physician has the legal authority to order the frequency of evaluations such as vital signs and that an order for discontinuation is a physician order. Not only is the hospital likely to lose the case, but the nurse could be charged by the Board of Nursing with exceeding scope of practice and negligence in not getting clarification when there are conflicting orders.

With respect to the telemetry order example, a nurse should not be discontinuing telemetry because the patient refused it. The order stands until discontinued by a clinician who has the legal authority to make a medical decision and write an order.

I advise nurses not to discontinue orders without a physician signature. Perhaps the hospital administrators who assigned this nurse to "clean up" Kardexes forgot to add "and get the ordering provider to enter a discontinuation order."

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....