Can't teach without an order

[NancyNurse100]

I have been in homecare for 28 years and am now being told I can not teach an identified problem without a physicians order. Lets just say I arrive at a patients home and they are having problems with constipation. This is an ongoing issue but was not identified on admission, so no interventions are addressed on the plan of care to address. So am I to understand that I can not on my own tell patients the basics, warm fluids as well as increasing fluids(no history of Fluid issues) high fiber diet etc without first consulting an MD? I have looked for the regs on this and can not find. Isn't that the reason for nursing diagnosis?? Not to say I would not inform the Dr, but not to go on and make proven suggestions sounds almost neglectful. I would really like to review the regulations where this is concerned.

[RN403, BSN, RN]

Is this a policy for your specific agency? Seems weird as a major part of being a nurse is providing education to our patients for their well being. Teaching is within our scope of practice.

[heron, ASN, RN]

Might it be a reimbursement issue?

[Karou]

Constipation is a nursing diagnosis (someone correct me if I am wrong). Why wouldn't you be able to educate the patient on prevention and treatment? I understand that the physician will need to be updated and the diagnosis added to the patients care plan, I don't understand why you can't educate in the meantime.

[KatieMI, BSN, MSN, RN]

It is reimbursement issue, all right.

Yes, constipation is nursing diagnosis, as well as a medical one. In many insurance plans, physician "compensated" for the job directly done - like, if he writes "Dx: constipation, chronic" and it is "coded" as primary, repeated, referral done/not, etc., the insurance after all pays accordingly. Nursing diagnosis is NOT coded, and officially NOT existed; therefore, if patient is educated by RN, starts to drink that prune juice and "recovers", doctor will lose "reimburcement" for not doing "his" job. It is the same for things like smoking cessation, weight loss and cholesterol control, to name a very few. In addition, if patient complains on constipation, gets educated, does it all and comes to the ER 3 months later with large bowel obstruction caused by cancer growing there, then the "nursing diagnosis" becomes a legal problem, as patient supposedly got treated by a person (RN) who was not licensed to do so and was working supposedly under doctor's license.

This is why old concept of "nursing" and "medical" diagnoses must stop crossing each other's road, IMH (umble)O. Instead of designing things copying medical without necessary knowledge and understanding of clinical part, like that "constipation", nursing diagnoses may start to be about things nurses see and able to correct, like "inadequate coping", "inadequate resources utilization" and "non-compliance". These diagnoses should be accounted for and "coded" just like medical ones, and then addressed and (gasp) reimbursed. Thus, nursing will start make money and, perhaps, after this happens, the tremendous role of nursing will at last get some recognition.

[Here.I.Stand, BSN, RN]

Well we can't recommend meds--that's outside our scope. But otherwise, why should we need a medical order to practice nursing?? Does this client need in-home nursing, or a service monkey??

ETA: That is not directed at you--it's directed at whoever's brilliant idea it was to decide nurses can't nurse.

[KatieMI, BSN, MSN, RN]

Well we can't recommend meds--that's outside our scope. But otherwise, why should we need a medical order to practice nursing?? Does this client need in-home nursing, or a service monkey??

ETA: That is not directed at you--it's directed at whoever's brilliant idea it was to decide nurses can't nurse.

Because it is a doctor who brings the money into, not nurse (s). Therefore, if nurses do something which potentially may decrease the money inflow, they should be stopped. Luckily, there is an universal and easy mean to do that by making that action "to be done only by doctor's order", however plain stupid it might look like and however idiotic explanations will be provided to justify it.

[Karou]

I know I am not the OP, but I was really baffled by her situation and wanted to thank those who responded with some great answers, because I learned from it. So it's basically the HH agencies way of ensuring proper billing/coding by physician diagnosis, ordered interventions, and treatment plans?

In general healthcare billing and insurance is really frustrating to me. I would rather work at McDonalds than deal with that mess (insurance/billing/coding).

[jadelpn, LPN, EMT-B]

Constipation itself is not a nursing diagnosis--"Altered Bowel Elimination" is. And with the paper trail of a care plan, there need to be the intervention part of it--which runs the gamut of medications to diet to whatever--and the medications have to be ordered by the MD. The MD may want a dietary consult--

If there is an issue that needs to be medically managed, then you do need to get some sort of order to cover yourself (and as others have pointed out reimbursement). Even OTC medications need an order. An agreed on goal, and what the patient is to do if the interventions are not working.

I was part of a survey once that the surveyor was looking for every patient that was on narcotic pain control had a Risk of Alteration of Bowel Elimination as part of their chart. And a bowel protocol in place. The bowel protocol was to be ordered by the MD. It was up to the nurse to chart accordingly. And to educate the patient on the bowel protocol as ordered by the MD.