LVN Scope in Texas

[wrigp, LVN]

I have a few questions about our scope in Texas. I'm currently working at a community mental health clinic and our DON and another ADN administrator are stating one thing and I'm not finding the support for this on BON's website like they are saying. The doctors are even disagreeing with them. (On a side note we don't have a EMR at this point. It is to be rolled out later this year but apparently they have been saying this for over 5 years now.)

1. BON has ruled that standard abbreviations for the sig on RX have to be typed out. Now mind you we have policy and procedures in place for medication documentation/administration. No where in there are specifications for what abbreviations can or can not be used. The doctor's even stated that Texas Board of Medical Examiners do not mandate this so why would TBON? Its my understanding that if the board doesn't take a position on the matter then it defers to the facilities Policy and Procedures. This is not addressed in the policy and procedures. My position on this, as well as the doctors and the other LVN, is that it is more difficult to read. This is only in regards to writing orders for record keeping purposes in the chart. This is not instructions given to clients.

Ex: Lith Co3 300mg 1 po BID needs to be written out Lithium Carbonate 300 Take one pill twice a day.

2. In our particular clinic we do not have a RN on site. Most other clinics do. The physicians act as our direct clinical supervisors. In other clinics an RN sees the client for a nurse follow up and the LVN's only admin injection or fill pill boxes. Since we do not and have not had an RN in this office for over 5 years, myself and the other LVN do all of the above. We do a focused clinical assessment as a follow up to the MD appointment approximately 3-6 weeks later. Our clients mental health is very predictable. We have a form that we use during said visit where we document all the appropriate information collected during the visit. My question is this:

When we complete a focus assessment for a known predictable illness for a client and there is no change in said client's condition from previous visits do we have to spell out all current symptoms to the MD prior to them giving an ok for medication refill?

According to the TBON position:

"The LVN collects data and information, recognizes changes in conditions and reports this to the RN supervisor or another appropriate clinical supervisor to assist in the identification of problems and formulation of goals, outcomes and patient-centered plans of care that are developed in collaboration with patient, their families, and the interdisciplinary health care team. The LVN participates in the nursing process by appraising the individual patient's status or situation at hand. Also known as a focused assessment..."

The doctors don't want to know that the client is still experiencing SI that are fleeting with no plan/intent and has been that way for years. The doctor doesn't want to know that ongoing issues with AVH are still presently active with no change in intensity/frequency. The doctors want to know what has changed from the last visit, if the medications that were changed have improved the symptoms they were targeting. If nothing has changed they always ok the refill. If something has changed or symptoms have increased we of course notify the MD about this and either they speak with the client directly or change medications during the consult and we inform the client. This has been going on for 6 years with one LVN and 2 years for myself. The reason I'm questioning this is because of a small TBON statement that states that the RN: "...Analyzes assessment data to identify problems, formulate goals and outcomes, and develops nursing plans of care for patients and their families."

The reason this has come up is because they do not want us to use our instant message system to let the doctor know there is no change in symptoms and client is requesting refill of medications prescribed at previous visit. They want us to type out exactly what the client said. I understand that it is my license if something happens and to CYA I would need to place all that in there. I just need an interpretation of the boards stance. Can I or can I not determine based on my focused assessment if the condition has changed?

[Asystole RN]

#1 If you cannot find an answer on the board's website then call or email.

I highly doubt the board would have a position statement on this, however, your employer leadership can instruct you to wear pizza on your head while you pass medications as a condition of employment.

I would recommend that if they wanted this to become a policy then it should be written as such.

[Horseshoe, BSN, RN]

Can I or can I not determine based on my focused assessment if the condition has changed?

http://www.bon.texas.gov/pdfs/practice_dept_pdfs/position_statements_pdfs/positionstatements2014.pdf

Texas Board of Nursing - Practice - Position Statements

From page 60 of the second link:

The second step in which the LVN participates and contributes to the nursing process is planning. After the focused assessment, the LVN reports data and other information such as changes in patient conditions to the appropriate clinical supervisor, such as a RN. This information may be considered in planning, problem identification, nursing diagnoses, and formulation of goals, teaching plans and outcomes by the RN supervisor or another appropriate clinical supervisor. A nursing plan of care for patients is developed by the RN and thus the RN has the overall responsibility to coordinate nursing care for patient.