I have a question regarding out patient clinic nursing care and the policies/regulations.
Situation: Orders are not placed for certain procedures pertaining to foley insertion/removal/void trials and wound care (simple and complex). The medical providers instead put documentation of what they want done in a progress note or in a comment box in the level of service section (where follow up information goes). I like to follow the rules and the facility has told me that documentation by provider is all that is needed. However when in nursing school
(I have been a practicing nursing for about 4 years), I remember having it drilled into us that we needed an order for everything. I realize we focused mainly on acute care and inpatient hospital systems. This is why I am here asking for any information regarding this issue. I have poured over the Texas Board of Nursing, Nurse Practice Act (I practice in Texas), and spent hours going through CMS documentation. I have found nothing that fits the situation.
Is an order required to provide the above stated nursing care?
If so is that requirement federal/state regulated, or is it facility regulated?
What constitutes an order in the setting of an EMR?
Does a progress note work or other documentation work?
If it is a facility regulated issue I am aware I will need to take it up with them, I am actively seeking clarification from the facility at present.
Thank you for any and all guidance.