Long-Term Care Survey Alert

A standing order can help or hurt depending on whether you have these controls in place.

You can manage many conditions in the nursing home with telephone and standing orders. But your facility should take steps to ensure that these types of orders improve rather than imperil resident care, stresses a white paper developed by the American Health Care Association in conjunction with the American Medical Directors Association.

Start with the who: State regulations and facility policies dictate who can receive the telephone or verbal orders, says Shehla Rooney, a physical therapist and consultant in Cookeville, Tenn.

And the person writing a verbal order should "clearly and correctly identify the ordering practitioner," including the correctly spelled name and credentials, such as MD or NP, advises the white paper. Also include the date and time you write the order.

Beware: Make sure the person providing a phone order has authority to do so, advises Clare Hendrick, a nurse practitioner and principal of ProTime in San Clemente, Calif. She has encountered situations where a nurse calls the doctor and gets orders from a clerical person or medical assistant who hasn't consulted with the physician to obtain the order. Do this: The nursing staff person should read back a verbal order to the practitioner to make sure he or she transcribed it correctly, advises the white paper.

Also: "Each state has its own requirement for when physicians have to sign and date phone orders," says Marilyn Mines, RN, RAC-CT, BC, manager of clinical services for F&R Healthcare Consulting Inc. in Deerfield, Ill. "In Illinois, it's within 10 days of the physician giving the phone order."

Documentation tip: When a nurse does obtain a phone order, she should document in the clinical record that she discussed the situation with the physician -- "and based on the following  assessments, etc., the physician wrote the order," advises Mines. Then reference the order on the physician order sheet, she adds.

Review Verbal Orders After the Fact

The facility should implement "a policy/procedure by which the nurse manager reviews the verbal orders from the night or day before," suggests Steven Levenson, MD, CMD, a multi-facility medical director in Baltimore, Md., and an AMDA past president, who was involved in developing the white paper.

"Verbal orders taken during off hours (weekends, nights) may often reflect a change in the resident's condition," Levenson says. "And some of the orders may be incorrect or problematic -- or be given by a physician on call who doesn't know the resident," he adds.

Preauthorized orders can help sidestep the need for the nursing home to obtain phone orders in some cases. The facility should work with the medical director to identify problems that don't need the doctor's time or may be addressed with a brief protocol, Levenson advises. But, as noted in the white paper, "standing orders depend on someone's judgment to conclude that a patient meets the criteria, which requires an assessment," Levenson stresses.

Example: "If someone is having abdominal pain and can't move his bowels, that may trigger a standing order related to constipation," he notes. "But someone should assess the person to see if he or she has a distended and/or tender abdomen, a fever, etc."

The protocol should also have boundaries, Levenson counsels. For example, the protocol might indicate that if a treatment prescribed by the standing order doesn't work within 24 hours, the facility staff must contact the physician, he says. The same holds true if a simple dietary change and increase in calories doesn't improve nutritional intake within a designated amount of time, he adds.

Beware: Relying on preauthorized protocols for common symptoms can cause someone to home in on an isolated symptom, missing the bigger picture, Levenson warns. For example, Levenson notes that hypothyroidism, which he detects "constantly," causes "a diverse range of symptoms." These include functional decline, a change in mental status, and "a change in weight and appetite."

Crisis management tip: Facilities should work with physicians to obtain standing orders in case a community emergency, such as a hurricane, etc., breaches communication, suggests Robin Bleier, RN, LHRMFACDONA, principal of RB Health Partners Inc., in Palm Harbor, Fla. Doing so is a "proactive approach to facilitate good care without violating rules and state practice acts," she says.

Resource: Read the white paper at www.ahcancal.org/facility_operations/clinical_practice/Documents/AHCAAMDAPhysicianOrdersWhitePaper.pdf.