Questioning Physician Orders: Your Right, Your Responsibility, Your Power

Disclaimer

This article contains information based on my education, professional knowledge, and clinical experience. I am not an attorney; this content is for informational purposes only and should not be construed as legal advice.

Introduction

You received an order from a physician. Your instinct tells you something is not right about it.

Many nurses ignore that instinct. They assume they must follow the order because a physician wrote it. They worry about being insubordinate. They worry about challenging authority.

This assumption is wrong.

Nurses have professional judgment. Nurses have professional authority. Nurses have the right and the responsibility to question orders that do not make sense or that could harm patients.

Understanding when and how to question an order protects you. It protects your patients. It protects your license. This is not about challenging physician authority. This is about exercising your professional authority.

This article walks you through your rights and your responsibilities. It explains what makes an order valid. It shows you when to question. It gives you case examples. It empowers you to use your professional judgment confidently.

The Fundamental Requirement: A Valid Order

Orders are not just suggestions from physicians. Orders are authorizations for you to act within your scope of practice.

For an order to be valid, it must be complete and signed by the ordering provider. A verbal order is acceptable in emergencies; however, it must be documented and countersigned within a specific timeframe set by your facility.

A complete order includes all the information needed to implement it safely. It is clear. It is specific. It does not leave interpretation to you.

An order that is vague or missing critical information is not a complete order. You should not implement an incomplete order. You should contact the provider and ask for clarification.

Your right to refuse an incomplete order is absolute. Your responsibility is to document why you did not implement it and what you communicated to the provider.

PRN Orders Require Objective Parameters

PRN means "as needed." Many nurses interpret this to mean the nurse decides when to give it.

This interpretation is wrong.

PRN orders must include objective parameters that define when the intervention is needed. These parameters guide the nurse's judgment. They do not replace the nurse's judgment; however, they establish the framework for it.

A complete PRN order specifies what condition triggers the intervention. It specifies the parameters that must be met. It specifies any limitations on frequency or quantity.

Vague PRN orders are incomplete orders. They lack the objective criteria needed to make a safe decision about implementation.

Your responsibility is to ask for specific parameters before implementing a PRN order. Your scope of practice does not include making clinical decisions that the order should have specified.

Scope of Practice: You Cannot Act Without Authority

Your scope of practice is defined by state law. It sets the boundaries of what you can do as a nurse.

Within that scope, you have the authority to practice nursing. You assess patients. You implement interventions. You evaluate outcomes.

However, you cannot perform medical interventions autonomously. Medical interventions require physician authorization. Each medication requires a specific order. Each procedure requires a specific order. Your authority comes from those orders.

You cannot modify orders. You cannot adjust dosages on your own judgment. You cannot implement medical interventions that were not ordered.

Your scope does not include acting as a substitute physician. Your scope DOSE include questioning when something seems wrong.

When to Question an Order

Several situations require you to question an order before implementing it.

The order seems clinically inappropriate for the patient. Maybe the medication is wrong for the diagnosis. Maybe the dosage seems too high or too low. Maybe the timing does not make sense.

The order conflicts with patient allergies or known contraindications. Maybe the patient has documented reactions to the medication. Maybe the medication interacts with other current medications.

The order could cause patient harm. This is your most important trigger. If implementing the order would harm the patient, you must question it.

The order lacks the required detail or parameters. Maybe a PRN order does not specify when to give it. Maybe an order does not specify the route or dosage.

The order appears to be outside the physician's scope of authority. Maybe a non-cardiologist ordered a complex cardiac intervention without consultation. Maybe the order exceeds what the physician is credentialed to order.

The order conflicts with other current orders or treatments. Maybe two orders contradict each other. Maybe the order contradicts current treatment goals.

The order is not signed or not properly documented. Maybe it is verbal without proper documentation. Maybe it lacks the required elements.

Your clinical judgment tells you something is wrong. Trust this instinct. Your experience and your education have prepared you to recognize problems.

The Nurse's Right to Refuse

You have the right to refuse an unsafe order.

This right comes from your professional authority and your responsibility to protect patients. No physician can order you to do something unsafe. No supervisor can require you to follow an unsafe order.

Refusing an order does not mean ignoring it. Refusing means you communicate with the provider about your concern. You explain why you will not implement it. You give the provider an opportunity to clarify or change it.

The provider maintains their authority to insist on the order even after you have raised concerns. If the provider insists on an unsafe order, you have choices. You can follow the order with complete documentation of your objection. You can escalate to nursing management. You can involve ethics committees or patient advocates.

What you cannot do is silently implement an unsafe order without documentation of your concern. What you cannot do is implement an unsafe order without communicating with the provider.

The Communication Requirement

Questioning an order requires direct communication with the provider.

This communication should be professional and specific. Do not say the order seems wrong. Instead, explain exactly what concerns you. Explain what parameters are missing. Explain what clinical concern you have.

Offer solutions when possible. If a PRN order lacks parameters, suggest what parameters might be appropriate. If a medication seems contraindicated, ask if the provider is aware of the allergy. Give the provider an opportunity to respond.

Document the conversation and any changes made. Write down what you communicated. Write down when you communicated. Write down what the provider said in response. This documentation protects you if questions arise later.

If the provider is unavailable, escalate appropriately. Use your facility's chain of command. Contact nursing management. Involve on-call providers if necessary.

Failure to communicate leaves you vulnerable. If something goes wrong, documentation will show whether you attempted to clarify the order or simply implemented it without question.

Case Example One: The Vague Imaging Order

A patient is admitted for observation with abdominal pain. The physician writes an order for "PRN CT scan without contrast for significant abdominal pain."

The problem is immediate. This order is incomplete. It lacks critical objective parameters.

What defines significant abdominal pain? Is any abdominal pain significant or must it meet certain criteria? Who determines when the pain is significant enough to warrant imaging?

The order does not specify when to implement it. It does not specify which provider must be notified before ordering the scan. It does not specify whether this is for acute pain or chronic pain. It does not specify what other interventions should be tried first.

A nurse could interpret significant abdominal pain one way. Another nurse could interpret it differently. This variability is unacceptable.

What should the nurse do? Contact the physician before implementing. Explain that the order lacks specific parameters. Ask what objective criteria should trigger the imaging. Ask whether the pain level on a scale should trigger it. Ask whether other interventions should be attempted first.

The physician's options are clear. Provide specific parameters. For example, "CT scan without contrast if patient reports abdominal pain greater than 6 on pain scale and has not responded to conservative measures." Clarify which provider should be contacted before or after implementing the order. Acknowledge the order is incomplete and revise it.

The documentation should reflect your communication. Write that you received an incomplete order. Write that you contacted the physician. Write what you communicated. Write what the physician said in response. Write whether the order was clarified or changed.

The learning point is critical. Orders that lack objective criteria are incomplete. PRN orders without parameters require clarification. Your responsibility includes questioning vague orders before implementing them.

Case Example Two: The Contraindicated Order

A patient with a documented penicillin allergy has an order written for penicillin.

This order requires immediate questioning.

The problem is clear. Administering penicillin to a patient with a documented penicillin allergy could cause serious harm. Anaphylaxis is a real risk.

The nurse does not need to wonder if this is intentional. The nurse does not need to assume the physician is aware of the allergy. The nurse must stop and communicate immediately.

What should the nurse do? Contact the physician immediately. State clearly that the patient has a documented penicillin allergy and the order is for penicillin. Ask if the physician is aware of the allergy. Ask if the order should be changed.

The physician's options are clear. Change the medication to an appropriate alternative. Verify the allergy in the chart. Clarify if there is a specific reason to override the allergy precaution.

The documentation must be thorough. Write that you identified a conflict between the patient allergy and the ordered medication. Write that you contacted the physician. Write exactly what you communicated. Write the physician's response. Write whether the order was changed. Write any explanation the physician provided.

If the physician insists on the penicillin despite the allergy documentation, this becomes a serious escalation. You would document the insistence. You would escalate to nursing management. You would involve additional oversight because this violates patient safety protocols.

The learning point is absolute. Your professional judgment protects patients. When you identify a safety issue, you act. You do not implement orders that could harm patients.

Case Example Three: The Incomplete Order

A patient with diabetes has an order written for "insulin as directed."

This order is incomplete, and it requires clarification.

The problem is that the order provides no guidance about how much insulin, when to give it, or what conditions should trigger it. The nurse is expected to make clinical decisions that should be specified in the order.

What triggers insulin administration? Blood sugar levels. The order does not specify the target range or the threshold for administration.

What dose should be given? The order does not specify dosage.

What type of insulin? Rapid acting, intermediate, or long acting? The order does not specify.

The nurse cannot make these decisions alone. The nurse's scope does not include deciding insulin dosages and parameters.

What should the nurse do? Contact the provider before implementing. Explain that the order needs specific parameters. Ask for target blood sugar range. Ask for specific dosage based on blood sugar readings. Ask for frequency of glucose monitoring.

The provider's options are clear. Specify the insulin type and dosage. Define the blood sugar parameters that trigger administration. Define the monitoring frequency. Acknowledge the incomplete order and revise it with specifics.

The documentation should reflect your communication. Write that the order lacked specific parameters for insulin administration. Write that you contacted the provider. Write what information you requested. Write the revised order details provided by the provider.

If the provider becomes defensive or refuses to clarify, document the response. Escalate to nursing management if necessary. Your responsibility is to have clear parameters before implementing insulin or any medication.

The learning point is practical. Many orders are incomplete. Your responsibility includes identifying incomplete orders and getting the information you need to implement them safely.

The Legal Protection in Questioning Orders

Understanding the legal implications protects you.

Documentation of your communication about unsafe orders protects you. If something goes wrong, the documentation shows you acted professionally. It shows you identified a concern. It shows you communicated with the provider.

Refusing an unsafe order protects your license. State boards of nursing expect nurses to question unsafe orders. They expect nurses to refuse orders that violate scope of practice or patient safety.

Following an unsafe order without question can result in board discipline.

Following an unsafe order without documentation puts you at serious risk. If something goes wrong, it looks like you knowingly implemented an unsafe order. The documentation shows whether you attempted to clarify or simply acted without question.

Your liability increases if you implement an unsafe order without questioning it. You cannot claim ignorance if the problem should have been obvious. You cannot claim you did not realize the issue. Your professional education obligates you to recognize problems.

State boards of nursing expect nurses to question unsafe orders. This is not optional. This is a core professional responsibility.

Hospitals and employers expect you to follow your scope. They expect you to refuse orders outside your scope. They expect you to question incomplete or unsafe orders. Following inappropriate orders puts liability on you and on your employer.

What Happens When You Refuse an Order

Several scenarios can unfold when you refuse an order.

Best case: The provider clarifies the order. You receive the information you need. You implement confidently. The issue is resolved professionally.

Middle case: The provider insists on the order as written. You follow the order with complete documentation of your objection. You note in the record that you questioned the order, and the provider confirmed their intent. This documentation protects you if questions arise later.

Difficult case: You have ethical concerns that override the order. The order violates patient safety principles that you cannot compromise on. Inform the provider that you will not be implementing the order and explain why. Escalating through the chain of command becomes necessary.

Nursing management gets involved. Ethics committees might be consulted. Patient advocates might be involved. These escalation procedures exist to protect you and to protect patients.

Chain-of-command escalation procedures vary by facility. Usually, you escalate to your immediate nursing supervisor. Then to nursing management. Then potentially to patient advocacy or ethics committees. Know your facility's procedures before you need them.

Involve nursing management when the provider refuses to clarify or change an unsafe order. Document everything. It is best to do this in writing to ensure there is a paper trail in case issues arise. Even if a conversation happens verbally, it is always best practice to send a follow-up email and retain it. By retaining it, I do not mean save it in your email. You may not have access to this email years down the road when litigation arises. Print the correspondence and secure it in your personal records. Make management aware of the conflict. Let them support your professional stand.

Involve ethics committees when ethical principles are at stake. Committees can provide an objective review. They can support your position. They can recommend courses of action.

Involve patient advocates when the patient is at risk. Advocates represent patient interests. They can escalate concerns. They can ensure the patient's voice is heard.

Your protection comes through proper escalation. Use the procedures available to you. Do not handle serious conflicts alone.

Documentation is Your Shield

Documentation is the most important tool you have!

Document exactly what you communicated. Do not write vague notes. Write the specific concern you raised. Write your exact words if possible. Write what information you requested.

Document when you communicated. Include the date and time. Include how you communicated. In-person conversation? Phone call? Text message? Each method of communication should be documented.

Document the provider's response. Write exactly what the provider said. Did they clarify? Did they change the order? Did they refuse to change it? Did they not answer? Document the exact response.

Document why you did or did not implement the order. Write that you received an incomplete order. Write that you questioned it. Write the outcome of your communication.

Specificity in documentation protects you. Vague notes do not help you if questions arise. Specific documentation shows exactly what happened.

Vague documentation leaves you vulnerable. If you write "contacted provider about order" without specifics, it does not clearly show what you communicated or what response you received.

Lack of documentation assumes you did not question the order. If there is no note about your communication, it appears you implemented the order without concern. The absence of documentation can be interpreted against you.

The Professional Responsibility Balance

You have multiple rights and multiple responsibilities. They work together.

You have the right to question orders. This right protects you and your patients.

You have the responsibility to question unsafe orders. This responsibility is core to nursing. It is not optional.

You have the authority to refuse incomplete orders. You do not have to implement orders you cannot understand or follow safely.

You have the obligation to communicate clearly. Questioning silently or through passive resistance does not count. Direct professional communication is required.

You have the duty to document thoroughly. Your documentation protects you. It shows what happened. It shows your professional judgment.

You have the professional judgment to make decisions. Your education and experience prepare you to recognize problems. Trust that judgment.

These rights and responsibilities work together. They create a system that lets you practice safely. They protect patients. They protect you.

Conclusion

Questioning orders is not insubordination.

Questioning orders is professional nursing.

Your scope includes professional judgment. You are not a robot implementing orders without thought. You are a professional with authority and responsibility.

Your authority includes the right to refuse unsafe orders. You can say no to an order that does not make sense. You can ask for clarification. You can escalate concerns.

Your responsibility includes protecting patients. When you see a problem, you act. You do not stay silent.

Your power comes from understanding your rights. When you know you can question orders, you do so confidently. When you know you can refuse unsafe orders, you stand firm.

Move forward with confidence in your professional authority. You have the right to question. You have the responsibility to protect. You have the power to make a difference.

Use all three!

Currently evaluating a case that involves the implementation of a physician’s order? Garvey Consulting & Education Services can assist you in analyzing the order's appropriateness and the nurse’s response. This can prove difficult, as documentation of the circumstances is often lacking. We have a team of competent medico-legal analysts who can ensure you get the correct information you need! Reach out to us today.

Visit www.garveyces.com to learn more about legal nurse consulting services and legal nurse consulting mentorship, or contact me directly at matthew.garvey@garveyces.com to discuss how our team can assist yours.

AI Assistance Disclosure

This article was developed, in part, with the assistance of artificial intelligence tools. The author has reviewed and edited all content to ensure accuracy and alignment with the author's professional expertise and opinions.