I am a nursing supervisor in a long-term care facility. It is my duty to notify the physician or nurse practitioner of any medical problems. Frequently, I take verbal orders and I write them on the physicians order sheet. Then I go over the order with the medication or charge nurse, and write a progress note. It is fairly common practice in my facility to take verbal orders, and other departments write them also. Does the person who takes the verbal order need to transcribe it?
Nancy Brent replies:
The protocol for taking verbal or telephone orders should be developed, adopted and placed in the policies and procedures manual of the facility.
Although variations may occur, the policy should consist of when verbal orders are acceptable, by whom they can be taken, how the verbal order is to be documented in the patient record (e.g., date, time, where placed), that the verbal order was read back and confirmed by the staff member taking it and the authorized prescriber, and that the verbal order is countersigned within a certain time period by the prescriber. The policy also should indicate that a nurse is authorized to take a verbal order from an authorized prescriber (e.g., ANP, licensed physician) and no one else.
It is a pretty clear principle of good documentation that the person taking the verbal order is the one who writes the order, pursuant to the facility’s policy.
You might want to read more about verbal orders to help you evaluate how your facility handles them. Some references include: Textbook of Basic Nursing, Rosdahl and Kowalski (2008), Lippincott, Williams and Wilkins; Complete Guide to Documentation, Second Edition, Lippincott, Williams and Wilkins; American Health Care Association White Paper: Physician Order Sheet And Verbal Orders, available at: htpp://www.amda.com/managementtools/PhysicianOrdersWhitePaper.pdf. This association is dedicated to long-term care medicine.