Ok to write a dx when taking order from physician?

I've got a question for you all. I've seen some nurses take orders from physicians and write them certain ways that I'm not sure is within our scope of practice? This question may seem silly, but i'm a new nurse and just wondering.

For example, one of my coworkers patients had just had a back surgery and his legs were numb, so the doctor ordered a CT scan of his lumbar spine.

The nurse wrote the order as follows: CT Scan of lumbar spine without contrast. Dx: numbness both legs.

Is it within our scope of practice to write the dx part? Granted this could just be for the ward clerk because they always have to put in the purpose for the scan.

[mustlovepoodles, RN]

I don't know that I'd put it as a diagnosis. I write down *exactly* what the physician says. If he says "diagnosis: numbness in legs", then that's how I write. But if he just says "CT Scan for numbness in legs", then that's the way I write it. You have to be careful writing diagnoses because as you pointed out, it's outside our scope of practice. But it's okay to write "for" or "due to".

[amb_lyn]

IMO, that's not a true 'diagnosis' necessarily. That's more of a "reason" for the scan. It's needed for any type of scan to be ran.

I think it's acceptable to write it in that manner.

[Elvish, BSN, DNP, RN, NP]

I'd write it, whether it's phrased 'for numbness of both legs' or 'dx: numbness of legs' or whatever. The 'diagnosis' in that case is not so much a medical diagnosis (say, nerve root compression) as a reason to prove to the beancounters that it's medically necessary.

[RNperdiem, RN]

Computer order entry for a CT scan has a required field for reason for the scan. The doctor will usually give a reason when ordering, otherwise CT scan is going to call and ask.

[nyteshade, BSN]

There should be a reason/purpose for stuff ordered. Insurance companies, Medicare and the like don't like to pay for services not needed.

[MC1906]

Like what has been said, I would write down exactly what the doctor ordered. This should be in the form of a telephone or verbal order being read back. Order entry may require a reason code be put in for billing, diagnosis or other reasons. Check with your charge nurse, manager/director and see what they prefer. You can also check with the radiology department and obtain a rationale from them as well.

[dscrn]

There should be a reason/purpose for stuff ordered. Insurance companies, Medicare and the like don't like to pay for services not needed.

and if the studies are outpatient. most places require not only a dx, but the correct dx code...

[Murse901, MSN, RN]

There's nothing wrong with writing a diagnosis with an MD's order if it's the MD's diagnosis. You are not stating that it's YOUR diagnosis, only documenting what the MD is telling you.

[shiccy]

I know that in our facility if an order for a diagnostic test is not written in a certain way then it will not be billed through insurance. If it's documented that the patient is admitted for BLE Numbness, then that is definitely what I would put in there as it's required. I don't think I'd be putting "Dx" though... Just BLE N&T would be what I would put. That way it's a physical finding and not a diagnosis.

Same thing for other tests as well. For example, if a person is in the hospital and starts coughing yellow / green sputum, we're not even allowed to write "rule out" or R/O anymore. It has to be for a specific reason like SOB, CP, green sputum, etc.

Gone are the days of being able to just irradiate our patients because we like the nice green glow at night! (or at least that's what the insurance companies would like the public to think was happening b/c if it didn't have one of the above reasons it wasn't important enough! )