When physicians won't comply, then document

At Swedish Medical Center in Seattle, verbal orders are accepted only when a patient’s life or limb is in danger; otherwise, the physician must write the order, says Judy Street, RN, manager of emergency services.

"I audit the process visually and staff receive verbal counseling if they are not following the standard," she says. "Support from our medical director has been key in making this work."

However, physicians occasionally are noncompliant, and when this occurs, nurses are asked to document this lack of compliance on a quality variance report. "The report allows us to track and identify a pattern of behavior," Street says. "This is reported through our organizational quality assurance process as well."

Once a pattern is identified, the ED medical director is responsible for addressing the problem. In addition, nurses are notified verbally and in writing, with notice sent to physicians, that if standards are not met, the nurse may be subject to formal verbal counseling.

"Physicians are advised they are putting the nurses at risk by not complying," Street says. "Peer pressure is a powerful tool."

Recently when a physician gave a verbal order for a nonemergent task to a nurse, two other nurses asked if the nurse was unaware of the standard. The nurse then turned to the physician and said, "You need to write it.’ Throughout the rest of the shift, the nurse made sure orders were written," she says.

Nurses also may report a problem with noncompliance to the ED manager or medical director via voicemail or e-mail, adds Street.

Another nurse was advised that continuing to accept verbal orders could result in corrective action. "The nurse was also told that if further incidents occurred, this would be part of her permanent file as well as reflected in her annual performance appraisal," she says.

If the physician gives a verbal order and the patient is injured as a result of the care ordered, the burden is on the nurse to prove that he or she fulfilled the physician’s order accurately, says Penny S. Brooke, APRN, MS, JD, a Salt Lake City-based nurse attorney specializing in health care legal issues.

"The nurse always should read the order back to the physician to verify that the nurse heard the order correctly," says Brooke. When orders are given by telephone, have a second nurse on the line to verify the order, she recommends. "It is always good to document details, such as a verifying witnesses’ name, in case you need to refresh your memory at a later date," she adds.

If a verbal order has not been signed by the physician in a timely manner, contact the physician to remind them, advises Brooke. "It is important to document this contact and to take the next steps if the physician does not follow through," she says.

If a physician refuses to comply, go up the chain of command and document this action, says Brooke. "Documentation of the steps taken to have a noncompliant physician sign a verbal order also may be submitted as an incident report," she adds. "Risk management is interested in having hospital policies and procedures followed."


For more information, contact:

  • Penny S. Brooke, APRN, MS, JD, Professor and Director of Outreach, University of Utah College of Nursing, Salt Lake City. Telephone: (801) 585-9610. E-mail: Penny.Brooke@nurs.utah.edu.
  • Judy Street, RN, Manager, Emergency Services, First Hill Campus, Swedish Medical Center, Seattle. Telephone: (206) 386-2592. E-mail: Judy.Street@swedish.org.