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Are RNs allowed to dictate a discharge summary for doctors?


Dear Nancy,

Are RNs allowed to dictate a discharge summary for doctors?


Nancy Brent replies:

Dear Frank,

Your question is quite broad and does not contain parameters from which a general response specific to the circumstances can be crafted. However, some general comments can be made.

Initially, if your question is based on a situation of an RN dictating into an electronic device a physican-authored discharge summary, with the instructions to the transcriber that you are the reader of the summary and the author is Dr. Jones (so that that name appears as author with you as the dictating nurse), this is an honest way to handle the situation. It should be noted, though, that the doctor can certainly dictate his or her summary as well as you can and should therefore do the dictating himself or herself. This arrangement assumes, by the way, that there is no facility policy against it or any other prohibitions against it (e.g., accreditation requirements).

If, in contrast, you mean that you as the RN author the discharge summary as though it were Dr. Jones’ and his or her name appears on the summary, this is legally problematic. As an RN, you do not have the authority to practice medicine, make recommendations for future treatment, order medications for the patient who is being discharged, and so forth. So, this role is outside the scope of your practice as a registered nurse and also places you in the position of falsifying the discharge summary. At a minimum, these two factors provide a basis for the board of nursing to discipline you.

If you are an advanced practice nurse and providing care to a patient, authoring a discharge summary on your own is well within your scope of practice under your state nurse practice act and its rules. Whatever role your collaborating physician would be required to do (e.g., sign the summary as well) would need to be adhered to as well if your state requires a collaborating physician and his or her review of discharge summaries.



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By | 2010-08-06T00:00:00-04:00 August 6th, 2010|Categories: Blogs, Nursing Careers and Jobs|0 Comments

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