You are in with a patient you believe will benefit from a treatment/medication. You call the provider, who either agrees with your recommendation as part of the SBAR (situation, background, assessment, nursing recommendation) or adjusts it to fit the situation better.

Most EMR (electronic medical record systems) now require you to enter a doctor’s (provider) order. For visiting staff, most EMR systems will send an electronic communication to the doctor to “sign” the verbal order within 24 hours (some systems, the next business day).

Can you imagine how many orders the provider must sign in a day? How do you protect your patient and your nursing license in the written documentation of the doctor’s order you enter into whatever system you use?

May I recommend the following template that has been working out well for our team?:

• Situation Review, including Recommendation (S&R from SBAR)
• Verbal order
• The goal for the patient if the treatment/medication is effective

Here are some examples:

Example 1 — Hypotension with falls

The patient’s blood pressure has been trending down over the past 30 days, with the most recent BP of 94/60; the patient has syncope x1 with a fall and injury to the face and neck due to suspected low BP. The patient has a chronic irregular heartbeat with the most recent pulse of 92. The patient is on 100 mg Losartan daily and 50 mg Metoprolol Tartrate BID. Recommendation to stop the Losartan

Order obtained to stop Losartan and continue to monitor BP and HR.

Goal: Stable BP, reduced fall/syncope risk, patient comfort

Example 2 — Patient suffering from frequent constipation

The patient has been increasing their use of morphine and lorazepam for shortness of breath with the side effect of increased episodes of constipation. Recommend starting Senna Plus 1 tablet BID, 17 Grams MiraLAX Daily PRN for constipation.

Order obtained to start Senna Plus 1 tablet PO BID routine, and 17 grams MiraLAX Daily as needed for constipation

Goal: Regular bowel movements

Our providers now rarely reach back out to us to clarify what they are singing, rarely end up changing the orders at IDG or via other situations, and the team knows the goal is patient-centered care. The fact that our licenses are better protected due to improved documentation is icing on the cake.