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Toni Talks about PT Today

Who Should Order PT?

Published April 28, 2010 10:15 AM by Toni Patt

This week I'm helping out on the acute side, which is foreign to me. I don't know anything about the doctors. I don't recognize any of the nurses. Every unit I've been on does things differently from what I am accustomed to. I had an experience with a nurse in MICU that has me wondering. I couldn't find orders for PT in the chart so I asked her. Instead of calling the doctor as I expected, she wrote the orders as a verbal herself.

On one hand, that's good. I had written orders in the chart. I could initiate therapy. My problem is that the nurse didn't actually get the orders from a physician. Her explanation to me was that the physician wouldn't mind and she did it all the time. OK, except according to her practice act she can only write an order after a physician gives it to her. According to my practice act, I must have a physician order.

I may be nitpicking but the point of having written orders is to confirm the order is what the physician wanted. Every facility I've worked at has a procedure for taking both verbal and telephone orders that includes reading the phrase back. Having written orders serves another purpose. It prevents individuals other than the physician from ordering things for the patient that may be unnecessary or contra-indicated.

I'm not saying that patient didn't need therapy. I would have a hard time arguing against therapy for any patient. A nurse can't write an order because the physician won't mind and she thinks the patient will benefit. Sure the patient will benefit but that isn't the point. If I use her logic, I could go around the hospital writing PT orders for every patient because he or she would benefit from therapy.

I don't know what sort of relationship the nurse and physician have. Maybe that particular physician is OK with nurses doing that. At some time, every therapist has gone to a nurse asking for orders on a patient. Usually the nurse writes them, often without contacting the physician. But there is a difference between working on a unit where it is understood therapy will be needed and working on a unit with critically ill patients. The situation makes a difference. Obviously the problem wouldn't exist if everyone followed the rules to the letter. One problem would be solved but a delay in initiating therapy could create a new one.

I can already see this fueling the fire for direct access in hospitals. I agree with the idea with reservations. Despite our DPTs, we lack the knowledge to manage critically ill patients. ICUs and MICUs might be an exception because there can be too much going on with the patients. Even the stroke team I work with defers to the ICU team for most orders. That is a topic for another day.

In the end, it depends on the comfort level of the PT and the nurse. I was lucky. The decision on what to do was taken out of my hands by another physician who needed to see the patient. One reason I don't agree with the practice is the potential for abuse. I do what I am comfortable doing. If I have any reservations, I can simply page the physician for clarification.

1 comments

The nurse should be written up, and had you simply accepted her order, you would be too.

Too often professionals do this forgetting that a particular MD is on vacation, off sick, or simply not on premises that day. Then what if DOH walks in? What if the orders never actually get signed? What if something adverse happens to the patient that has nothing to do with what you've done, but the notes go to court? What if the nurse is simply arrogant or too busy to be bothered with proper procedure? What if it were another less skilled, less ethical therapist?

You jeopardize the well being of everyone; patients, staff, and the institution you work for by this practice.

Dean Metz April 28, 2010 1:11 PM

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