Medical Screening Exam at triage by RN

  1. Do you do the official EMTALA required MSE at your triage. We are getting ready to change from normal triage then MD medical screening exams to MSE done by the triage RN. That is, if our manager gets his way. I think there must be some formal training required but manager doesnt seem to think so. I know that we do a heck of a job at triage assessing med emergencies vs non-emerg. We already order many tests from triage to facilitate flow without the MSE having been done by MD yet. It still feels like we are taking on too much without further training to say now "triage is the MSE". The ENA seems not to recommend that triage be the MSE. your thought and experiences would be helpful.
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  2. 16 Comments

  3. by   amberfnp
    RNinED,

    Are you implying that the nurses will be doing the MSE that the MD's usually do? I have never heard of that, although when I googled it, sure enough one of the first things that came up was from the Oregon Board of Nursing stating it is within the scope of practice for an RN to complete the MSE and it seems that this decision is up to the facility. Not sure if it is state regulated.

    http://www.oregon.gov/OSBN/pdfs/policies/EMTALA.pdf

    "RN Role and Requirements
    [FONT=Verdana,Verdana]
    The Oregon State Board of Nursing affirms that it is within the role and scope of practice for the Registered Nurse (RN) to perform a medical screening examination (MSE). Further, the Board believes that MSEs are beyond the scope of practice for the Licensed Practical Nurse, or the tasks allowed for unlicensed assistive personnel. It also is the Board’s position that the RN completing the MSE is establishing the presence or absence of an emergency medical condition, and is not engaged in making an independent medical diagnosis or developing a medical treatment plan."

    What other assessment steps beyond triage would you be required to perform to be considered an MSE?
  4. by   RNinED
    Thankyou, I will look up california's BRN for their rules. I don't think we would be doing anything more than we already are but the charges for the tests..labs, xrays and the visit could be applied to the pt even if they AMA. as it is now, if the MD doesn't actually lay eyes on them the pt can not be charged after these tests if they AMA before the MSE. Big loss of revenue, and wasted resources. (medical/medicare will not reimburse for tests without the MSE). Again thankyou for the information. I will feel better about it if the Ca. Board of nurses says it is within my scope.
  5. by   RNinED
    OK, I CAN NOT FIND ANYTHING FROM CA. BRN THAT SAYS OK FOR RN TO PERFORM MSE AT TRIAGE. I DID FIND AND PRINTED OUT OREGON'S STATMENT AND IT REQUIRES THAT THE HOSPITAL PROVIDE A GREAT FRAMEWORK FROM ALGORYTHMS TO SPECIFIC TRAINING FOR EACH RN REQUIRED TO DO THE MSE. DO ANY CALIFORNIA RNs CURRENTLY PERFORM THE MSE IN THE ED TRIAGE????? IF SO WHERE DO YOU GET THE INFO ON YOUR LIABILITY ETC. THANKS
  6. by   CraigB-RN
    Quote from RNinED
    OK, I CAN NOT FIND ANYTHING FROM CA. BRN THAT SAYS OK FOR RN TO PERFORM MSE AT TRIAGE. I DID FIND AND PRINTED OUT OREGON'S STATMENT AND IT REQUIRES THAT THE HOSPITAL PROVIDE A GREAT FRAMEWORK FROM ALGORYTHMS TO SPECIFIC TRAINING FOR EACH RN REQUIRED TO DO THE MSE. DO ANY CALIFORNIA RNs CURRENTLY PERFORM THE MSE IN THE ED TRIAGE????? IF SO WHERE DO YOU GET THE INFO ON YOUR LIABILITY ETC. THANKS
    EMTALA itself allows RN's to do the medical screaning exam. However the facility needs to have specific policies and procedures in place. Any time you impliment new policies and procedures, there should be some form of education and training to accompany it. However, it is usually up to the facility to determin what that training is. The facilty also gets to determine what is elegable for a MSE.

    Nurses doing the MSE doesn't increas the risk and liability, but nurses doing it without protocols/procedures and policies does.

    The MSE doesn't say they won't be seen, just says that if they want to be seen they ahve to pay the copay first and their insurance may not cover the visit.
  7. by   mmutk
    Only an advanced practitioner can do a MSE. In our triage a FNP or PA comes over to do it, if they need it.
  8. by   ZippyGBR
    Quote from mmutk
    Only an advanced practitioner can do a MSE. In our triage a FNP or PA comes over to do it, if they need it.
    do you have some evidence to back that assertion up - as other posters have suggested that their BON and EMTALA it;self doesn't make that stipulation and have backed that up ?
  9. by   CraigB-RN
    Quote from mmutk
    Only an advanced practitioner can do a MSE. In our triage a FNP or PA comes over to do it, if they need it.
    EMTALA by itself does allow for RN's to do the screening. There MAY be some BON regulations out there that limit this. There ARE many facilities that don't allow this, for many reasons. Liability revenue, or other reasons.

    I know or a fact that it is allowed under EMTAL itself. I was a DON for a multihospital organization and we looked into it. Decided not to allow RN's to do it, for political reasons.
  10. by   obliviousRN
    I'm in Oregon and we do MSE's at our facility.

    First and foremost we determine emergent vs. non emergent (MSE) - this may include some labs and/or Xrays. We then triage them into the order to be seen. It is 2 separate procedures, but you basically do them at the same time. You just chart it differently.

    Say for example, you do an MSE on someone with ankle pain. We deem them non-emergent so we discharge them from the ER and recommend follow up in clinic the next day. We may have ordered an Xray or not per our clinical guidelines depending on swelling, deformity, etc.

    Change that to MSE on someone with ankle pain with obvious deformity and open area in skin. Xray ordered per clinical guidelines shows fracture, possibly open so MSE = emergent. They are then triaged into the appropriate level and seen in the ED by the physician.

    It gets confusing at times, but you really are doing it all at once. It just matters how you document. Clearly define your MSE in your documentation and then assign them a triage level separately.
  11. by   BrnEyedGirl
    just curious,...if the c/o is ankle pain,.the xray is done,..who reads the xray? ..are you suggesting the triage nurse reads the xray and decides there is no fx therefore no emergency??,..or does radiology read all the xrays stat? I can see where this could be a great thing to weed out many of the frequent flyers that come in with a different pain every week or the "I can't breathe" while talking on the cell phone, O2 sats 100% ORA,...but I can also see how this would add a huge amount of liability that I'm not sure I want,..too many lawyers in the world for me!
  12. by   obliviousRN
    The radiologist reads the Xray. We wait for the dictated report. Doesn't take long at our facility as it is not a huge ER.
  13. by   CrisRNMSNCEN
    Medical Screening exams are outside of the RN scope of practice and only NP or PAs if the hospital Medical bylaws agree. You have to ask yourself what will be needed to completely medically screen a patient? Can you order a CAT scan on your license only? No so if someone comes in with the "worst headache" a medical screen would require a CT.. that should answer your MSE questions.. NO MSE by RNS . And EMTALA does not have within its scope the permission to perform MSE by an RN.. the State board does.. good to be knowledgeable of your state board and healthsystem policies as well as ENA ..
  14. by   LLLLiiiFFEsaveer
    Quote from CrisRNMSNCEN
    Medical Screening exams are outside of the RN scope of practice and only NP or PAs if the hospital Medical bylaws agree. You have to ask yourself what will be needed to completely medically screen a patient? Can you order a CAT scan on your license only? No so if someone comes in with the "worst headache" a medical screen would require a CT.. that should answer your MSE questions.. NO MSE by RNS . And EMTALA does not have within its scope the permission to perform MSE by an RN.. the State board does.. good to be knowledgeable of your state board and healthsystem policies as well as ENA ..
    It obviously depends on where one works. The triage protocols are very extensive where I work. I have ordered several CAT scans on patients from triage. One example, would be the patient who had a headache located directly behind one eye (pain began 5 days ago). Their were a couple of other s/s too, but otherwise negative on the cincinatti stroke scale. Lobby wait times were crazy that night (even for ESI II's), and I just had that feeling for this patient, something was not right? Within 45 minutes of this patients registration time, I was reading the radiologists interpretated results of glioblastoma (sad). I am not sure by what you ment of ordering these scans on your license "only", but yes, we'll order practically any test we deem necessary from triage (even if that means placing an IV just prior to CT transport, etc...)

    I am not too sure on the whole MSE being done by the triage RN though? That just seems like a bit to much for us to shoulder - having to triage, screen, order the appropriate tests, and discharge certain patients without them ever having been seen by an MD... That does not sit well with me.

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