Admission Evaluations and the DSM

[onegoodnerve]

Question for all of you seasoned psych nurses. I recently started a position on an adult unit and at this facility nurses are to perform evaluations on ED patients who are on a psych hold. For Example, if someone comes into the ED voicing or displaying any psychiatric s/s, the Dr will order a PET(psych eval). One of the nurses form the unit will come to the ER and ask the pt and series of questions to determine if they warrant inpatient admission, outpatient tx, or d/c home. The eval form is 9 pages long and also includes a section where the nurse has to fill in each axis of the DSM-IV. I was of the understanding that only a physcian or ANP could complete the DSM. Now let me say that I don't have a lot of psych experience, I've done a year of geri-psych in MO and I currently live in GA. Where I came from nurses didn't do these type of evaluations of patients. We had intake coordinators and/or doctors to perform the initial assessments on our ED patients. My preceptor let it slip that this is normally 6 months of training to do PETS, but I only have 3 days to get it. I just feel uncomfortable with this process, having the responsibility to determine pts fate makes me nervous. Do any of you all perform these type of evaluations in your facilities? Thank you in advance for the advice.

[Davey Do]

The Nurses and Social Workers who perform the Initial Assessment in the ER at the Medical Center where I am employed give a sort of Preliminary Diagnosis, but it's the Psychiatrist who gives the Definitive Diagnosis.

The Preliminary Diagnosis is made based on a collective group of symptoms that match the DSM's or, if the Patient has a history of admissions, on past admissions' diagnosis.

The Preliminary Diagnosis made by the Nurses and Social Workers are utilized as merely a tool in giving an idea, or communicating a Patient's overt symptoms, to other Professionals. Rarely is the Preliminary Diagnosis wrong, but every now and then the Psychiatrist will make a change.

Besides, when the Psychiatrist is contacted for admission orders, the Diagnosis is a part of those admission orders, and is given at that time.

[Meriwhen, ASN, BSN, MSN, RN]

The Preliminary Diagnosis is made based on a collective group of symptoms that match the DSM's or, if the Patient has a history of admissions, on past admissions' diagnosis. The Preliminary Diagnosis made by the Nurses and Social Workers are utilized as merely a tool in giving an idea, or communicating a Patient's overt symptoms, to other Professionals. Rarely is the Preliminary Diagnosis wrong, but every now and then the Psychiatrist will make a change.

This. You're not officially diagnosing patients, just assessing and stating what you think that they may be presenting with based on their symptoms, history, etc. Think of it as giving a report on the patient: "Because of X, Y and Z, I think they have Major Depression/Borderline Personality Disorder/Alcohol Dependence/whatever." The MD will make the official call.

[onegoodnerve]

Thank you guys for the input. The process at this facility is just so different from what I'm accustomed to. And I just have some reservations about there only being one nurse on the unit, when the eval nurse is in the ED doing assessments. I just don't think that is safe at all. Thank you guys again!

[pro-student]

I completely disagree. I don't think it is ever appropriate for an RN to document a medical/psychiatric diagnosis they suspect. That is beyond the scope of practice and would likely be construed as practicing medicine without a license if litigation was ever involved.

Think of it this was- for medical conditions, nurses often suspect a diagnosis before the physician/APRN does their assessment and diagnosis but it would never be acceptable to the nurse to document this. The same is true in psych. What the form should be asking and would be within the scope of practice for RNs is to document any PREVIOUS diagnoses but not to make any (either speculative or outright) of their own accord.

While psych is unique in that RNs more often weigh in on diagnosis, it is most definitely not part of nursing education or accepted scope of practice. APRNs in psych go through advanced training and supervised practice before being licensed to add diagnosis of mental illnesses to their scope of practice (including all of the 5 axises).

[Whispera, MSN, RN]

I did emergency department evaluations for awhile. What I did was call the psychiatrist and tell him the symptoms the patient was having. He would make a preliminary diagnosis based on that, and that's what I wrote down on the paperwork. Then, when he saw the patient, he could make changes as needed. At the hospitals where I worked, a diagnosis was required for admission, and there were no psychiatrists who worked in the building as staff. They came over as soon as possible, from their offices to do what needed to be done.