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Can nurses accept a patient on a unit and give a diagnosis without contacting the physician?

Dear Nancy,

Is it legal for nurses to accept a patient on a unit and give a diagnosis without contacting the physician?

Maureen

 

Dear Maureen,

Your facility has a policy and procedure for admitting patients into the hospital and on specific units and this policy should be followed without exception.

It is assumed the policy includes the following: Patients are admitted upon an order of a healthcare provider who has admitting privileges (e.g., licensed physician, licensed advanced practice nurse, licensed oral surgeon), and who also provides the hospital staff with a diagnosis and any standing or other orders for the nursing staff to follow. The policy most probably also requires the nursing staff to notify the admitting healthcare provider when the patient is admitted.

As a staff nurse, you do not have the authority to admit a patient and provide a diagnosis unless after all of the requirements of your policy are met, you make a nursing diagnosis.

If you have not reviewed your institution’s policy and procedure on admissions, you should do so. Other resources would be your nurse manager or CNO, or the admitting office. Be sure to get clarification on any concerns about the admission process so you can comply with its requirements.

Regards,
Nancy

By | 2015-09-03T14:38:17-04:00 September 7th, 2015|Categories: Nursing careers and jobs|3 Comments

About the Author:

Nancy J. Brent, MS, JD, RN
Our legal information columnist Nancy J. Brent, MS, JD, RN, received her Juris Doctor from Loyola University Chicago School of Law and concentrates her solo law practice in health law and legal representation, consultation and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent has conducted many seminars on legal issues in nursing and healthcare delivery across the country and has published extensively in the area of law and nursing practice. She brings more than 30 years of experience to her role of legal information columnist. Her posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.

3 Comments

  1. Avatar
    maryjane Woodring June 23, 2016 at 3:39 am - Reply

    Can a nurse change a neurologist diagnosis?

  2. Avatar
    Margaret May 24, 2019 at 2:56 pm - Reply

    Dear Nancy,
    In a Hospital setting:
    Would it be legal, risky and time consuming – if during an emergency/urgency event (a high tension moment), a nurse receives a verbal order to override a drug and is requested to register in the Automatic Dispensing Unit (ADU) the reason for overriding a drug by posting symptoms or diagnosis (e.g. seizure, agitation, intubation, etc.) in the ADU before he/she removes the drug from the ADU?

    It is a regular practice here – post emergency/urgency events for drug overrides – the healthcare staff involved in the emergency/urgency event does a debriefing to assure all drugs and dosages were properly ordered and administered after the tension is low, then the Physician registers the order in the patient’s record and nurse documents the administration in the patients record.

  3. Avatar
    Greg Lovering June 2, 2019 at 2:43 am - Reply

    Sometimes; here’s an example….a new admission does not have depression listed as a Dx…but has fluoxetine 100mg PO BID for depression in the signed meds list…in that scenario, it’s usually ok to add depression as a Dx because the doc signed off on the Dx on the orders sheet.

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