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Can Nurses Document Medical Diagnoses in Patients' Charts?

Nurse reviewing tests and charts

A registered nurse (RN) says she works at a clinic where nurses attend to patients with common symptoms such as coughs, minor cuts or abrasions, and sore throats. The nurse is authorized to provide patients with some guidance and recommend over-the-counter (OTC) medications. A physician signs off on patients' visits and completes the documentation in the electronic medical records (EMR). 

Currently, however, nurses are required to input a medical diagnosis from a predetermined list before a physician reviews the EMR notes. However, the clinic is contemplating changing the list and establishing a "master list" of diagnoses based on patients' symptoms (e.g., if a patient has a cough and sore throat, enter diagnosis X). The nurse is concerned that making a medical diagnosis is out of her scope of practice and that there might be liability risks in doing so.

Medical diagnosis vs. nursing diagnosis

The existing documentation practices are bothersome for several reasons. First, are her decisions and documentation considered a medical diagnosis? A medical diagnosis is made by a physician or other advanced practice healthcare professional and focuses on identifying a disease, a disorder, or an illness, based on symptoms, a patient's history, diagnostic tests, and a thorough examination of the patient. A medical diagnosis doesn't change, even if it's resolved, and remains a part of the patient's history. Examples include diabetes mellitus, cancer, and congestive heart failure

In contrast, NANDA International, Inc., defines a nursing diagnosis as "a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability." Such a judgment is based on a "comprehensive nursing assessment." Examples might include a sedentary lifestyle or chronic constipation

If the proposed master list can be designed to accurately reflect a patient's symptoms based on the comprehensive nursing assessment, and if the resulting diagnosis is categorized as a nursing diagnosis, it would address any concerns regarding the issue of medical diagnosis. Additionally, this approach would also resolve another concern in the current procedure, which involves the physician signing off on the patient's visit and "completing" the note.

Nurses' charting is a critical piece of a patient's care. It should accurately reflect their assessments and interventions and must be signed by each nurse. It's not the physician's responsibility to add to the nursing notes. Instead, physicians should enter their notes separately and sign those entries. This serves as additional documentation alongside the nurses' notes.

Another issue is that RNs are prescribing OTC medications. RNs can’t prescribe any medications, including OTC meds. Standing orders for common OTC medications can be developed by physicians and incorporated into the current assessment process in which patients are initially seen by the RNs. Because the standing orders are developed by the physicians on staff and followed — not initiated — by the RNs, this should eliminate any concerns that RNs are prescribing medications, which is outside their scope of practice.

To make sure, RNs should review their state Nurse Practice Act for guidelines that address standing orders. Also, check the state board of nursing’s (BON) website to determine if the board has issued a position statement on this issue. All changes must conform with the state Nurse Practice Act’s definition of professional nursing practice for RNs.

The chief medical officer’s (CMO) assessment that the current procedure is within the RN’s scope is gracious, but the CMO isn’t the ultimate determiner. The chief nursing officer (CNO) should be the administrative person who evaluates this issue. The CNO might also want to consult with the state BON for guidelines and other CNOs to find out how they handle the initial nursing assessment and documentation in the EMR.

Guideposts for your practice

If you find yourself in a practice situation that may not align with your scope of practice, you need to find out whether the procedure in question is included. Doing so will eliminate legal problems for you in the future if a patient is injured by your participation in the procedure, or you're alleged to be practicing outside your scope of practice. 

Sharing your concerns with your CNO and risk manager would be the first step. Your next step could be seeking a legal opinion from an attorney who represents nurses in professional licensure proceedings.

Whatever you do, don't keep silent. Don't rely on an opinion about your concerns that you're not sure is accurate. Rather, be accountable and responsible for your nursing practice by clarifying any aspect of your practice that you question in good faith.

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