Medical Diagnosis and the Nurse’s Scope of Practice

As a Nurse Life Care Planner, I am often deposed regarding my opinions and work product for the attorneys who ask me to consult on catastrophic injury cases.  One of the questions I am hit with most often deals with diagnoses.  While I am not a doctor, I can make a diagnosis…a nursing diagnosis.  A nursing diagnosis, however, is not a medical diagnosis.  Assigning a medical diagnosis is outside of my scope of practice.

A popular Medscape article addressed this distinction as it relates to electronic medical records (EMR).  Nurses are being called on to enter medical diagnoses in the system.  Attorney Carolyn Buppert outlines what is and is not within a nurse’s scope of practice when it comes to this topic.

• The key point to remember is this…
• copying information from a medical provider and entering it into the system is okay
• assuming the reason for admission is not
• making your own opinion as to what the medical diagnosis is is not okay

It may have been awhile since you reviewed your scope of practice.  I advise you to do so soon and regularly.  Consider highlighting those areas that you need to brush up on, or areas that are particularly meaningful to you. Spend time really thinking about each section and apply scenarios to each. It might surprise you at just how large your scope really is, or perhaps you will find that it is more narrow than you tend to practice.

Reviewing my state’s Nurse Practice Act is something I do before each deposition. Access to the ANA Scope and Standards of Practice can be found here, and specifics with regard to Arkansas are also available online.

Related articles

• What is Nursing Diagnosis – And Why Should I Care?(nandainternational.typepad.com)

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