Performing Vital Signs Without a Policy

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I work for an insurance company doing home visits. The state has requested that we take vital signs every 3 months when we visit. My company does not have any type of policy, protocol, or even algorithm in place. I'm concerned about the liability. What rights do we, as RNs, have? Thanks!

Riawahine

Specializes in Managed Care.

Yes--that's is exactly our concern: guidance for the abnormal values. Thank you for your response.

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Specializes in Managed Care.

Thank you, Michael. You hit the nail on the head. I am planning on consulting an attorney because my management just doesn't get it. They aren't in the field putting their license on the line. Your post was extremely helpful.

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Specializes in Pedi.

Nursing judgment is a big factor when seeing patients in the home. If the patient has a temp of 99.9, big deal. He can take a tylenol if he doesn't feel good. If his BP is 200/120 and he has blurry vision and a headache, call 911. It's not like if you go into a home and find a school aged child in bed breathing at 100 breaths/min with a HR of 160 and a BP of 140/100 (as I did once last year) you're going to say "oh I can't do anything until I consult my company's guidelines." As a licensed nurse, you should be able to tell by looking at this child that he's in trouble and that 911 needs to be called immediately. Same thing applies even WITH guidelines. For example, in Oncology our standard is that the clinic needs to be called if a child has a fever > 38 C twice in 24 hours (with readings taken 1 hr apart) or > 38.5 C once. When I went in and found a kid looking like crap the other day with a temp of 100.9 F (38.3 C) and a mother who doesn't really get it/just wanted to give Tylenol, I relied on my nursing judgment over the established guidelines and called anyway. Sometimes we send these kids in before they hit 38 C twice because we know the parents will either not recheck them or give them tylenol to mask a fever so they don't have to take them in.

I don't see the big deal.

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Thank you, Michael. You hit the nail on the head. I am planning on consulting an attorney because my management just doesn't get it. They aren't in the field putting their license on the line. Your post was extremely helpful.

i guess I'm not clear on exactly what your position is? Does it include a physical assessment for insurance purposes? If so a complete set of vitals is a part of a physical assessment, so why would it be a problem?

If what you are concerned about is parameters, than why not draft a policy before involving a lawyer? Do you work under a physician? Or just independently? It would not be difficult to draft a policy stating what the companies parameters are, and what actions are to be taken seriously parameters could be as simple as "if bp is above xxx instruct client to call pcp for an appointment". Or you call the pcp with bp reading. Clearly clinical judgement plays a role. If you arrive and the hypertensive client is having weakness to one side you call 911.

As as to liability of the client doesn't follow through, as long as you have charted "client instructed to do XYZ" you are not responsible for what they choose to do or not do once you leave. Which is the reality in home health as well.

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Specializes in Managed Care.
Nursing judgment is a big factor when seeing patients in the home. If the patient has a temp of 99.9, big deal. He can take a tylenol if he doesn't feel good. If his BP is 200/120 and he has blurry vision and a headache, call 911. It's not like if you go into a home and find a school aged child in bed breathing at 100 breaths/min with a HR of 160 and a BP of 140/100 (as I did once last year) you're going to say "oh I can't do anything until I consult my company's guidelines." As a licensed nurse, you should be able to tell by looking at this child that he's in trouble and that 911 needs to be called immediately. Same thing applies even WITH guidelines. For example, in Oncology our standard is that the clinic needs to be called if a child has a fever > 38 C twice in 24 hours (with readings taken 1 hr apart) or > 38.5 C once. When I went in and found a kid looking like crap the other day with a temp of 100.9 F (38.3 C) and a mother who doesn't really get it/just wanted to give Tylenol, I relied on my nursing judgment over the established guidelines and called anyway. Sometimes we send these kids in before they hit 38 C twice because we know the parents will either not recheck them or give them tylenol to mask a fever so they don't have to take them in.

I don't see the big deal.

I think you're missing the point: you have written guidance to use WITH your clinical reasoning and critical thinking. We have NOTHING! Not even anything that says, call the doctor or 911. I work with nurses that have zero bedside experience and don't have a real frame of reference for what to do in the field. We have to do something for abnormal VS, and we have to be consistent in those actions. We need a Standard of Care. Have you ever had to testify in court against a colleague? If you have, then you know it's very unpleasant. I don't want to be in that situation, again. Sorry you think taking vital signs is no big deal

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Specializes in Managed Care.
i guess I'm not clear on exactly what your position is? Does it include a physical assessment for insurance purposes? If so a complete set of vitals is a part of a physical assessment, so why would it be a problem?

If what you are concerned about is parameters, than why not draft a policy before involving a lawyer? Do you work under a physician? Or just independently? It would not be difficult to draft a policy stating what the companies parameters are, and what actions are to be taken seriously parameters could be as simple as "if bp is above xxx instruct client to call pcp for an appointment". Or you call the pcp with bp reading. Clearly clinical judgement plays a role. If you arrive and the hypertensive client is having weakness to one side you call 911.

As as to liability of the client doesn't follow through, as long as you have charted "client instructed to do XYZ" you are not responsible for what they choose to do or not do once you leave. Which is the reality in home health as well.

I appreciate your response. Let me clarify: the State came up with idea to obtain VS on members receiving Medicaid. They are not our "patients". There are 5 health plans doing this (all the others have written guidance for their nurses) and if we are all calling the same doctor (I live in Hawaii and since it's an island, many of our members have the same provider) throughout the day, we probably aren't going to get to speak to him/her, if we can even get through at all. We do not work under a physician and don't have any standing orders. That would be great if we did. Obviously if the member is in acute distress calling 911 is a no-brainer. It's those border line members, and they all have multiple co-morbidities.

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i guess I'm not clear on exactly what your position is? Does it include a physical assessment for insurance purposes? If so a complete set of vitals is a part of a physical assessment, so why would it be a problem?

If what you are concerned about is parameters, than why not draft a policy before involving a lawyer? Do you work under a physician? Or just independently? It would not be difficult to draft a policy stating what the companies parameters are, and what actions are to be taken seriously parameters could be as simple as "if bp is above xxx instruct client to call pcp for an appointment". Or you call the pcp with bp reading. Clearly clinical judgement plays a role. If you arrive and the hypertensive client is having weakness to one side you call 911.

As as to liability of the client doesn't follow through, as long as you have charted "client instructed to do XYZ" you are not responsible for what they choose to do or not do once you leave. Which is the reality in home health as well.

As part of the underwriting process without any sort of POC, I wouldn't think the nurses would be legally authorized to instruct the patient anything, outside of call 911.

On the flip side, if they document a BP of 160/95 and the client infarcts after the nurse left (yeah I know but Im just making something up as potential liability) would that nurse have any liability? Can an RN ever ignore a non critical abnormal finding when they are acting in the capacity of an RN (doing a nursing assessment) but not under any sort of POC (works for the insurance company)? Would have advising client to call their Dr be enough? What if that patient didn't have the wherewithal to follow up appropriately?

Maybe my imagination is a little far fetched tonight.

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I appreciate your response. Let me clarify: the State came up with idea to obtain VS on members receiving Medicaid. They are not our "patients". There are 5 health plans doing this (all the others have written guidance for their nurses) and if we are all calling the same doctor (I live in Hawaii and since it's an island, many of our members have the same provider) throughout the day, we probably aren't going to get to speak to him/her, if we can even get through at all. We do not work under a physician and don't have any standing orders. That would be great if we did. Obviously if the member is in acute distress calling 911 is a no-brainer. It's those border line members, and they all have multiple co-morbidities.

Does your job require a physical assessment though? Or are you strictly there in an educational / counciling capacity? If you are there to do a physical assessment, then vitals should be a part of that. Creating a policy that covers you for what is considered abnormal and what is not is a good thing. If youre company is not on board and won't support your effort to do that then its probably not a great place to be.

For what its worth, in home health we call abnormals to a doctors office. For the most part we speak to a nurse, and I tell the doctors office to call the client directly if they want to make changes or see them. If they have new orders for me (recheck bp in 2 days or some such), I take the order and enter it.

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As part of the underwriting process without any sort of POC, I wouldn't think the nurses would be legally authorized to instruct the patient anything, outside of call 911.

On the flip side, if they document a BP of 160/95 and the client infarcts after the nurse left (yeah I know but Im just making something up as potential liability) would that nurse have any liability? Can an RN ever ignore a non critical abnormal finding when they are acting in the capacity of an RN (doing a nursing assessment) but not under any sort of POC (works for the insurance company)? Would have advising client to call their Dr be enough? What if that patient didn't have the wherewithal to follow up appropriately?

Maybe my imagination is a little far fetched tonight.

If there is a policy in place of what to do with abnormals than no, I don't think a nurse would have to call 911 for asymptomatic abnormals.

If the nurse left a client with a clearly high blood preassure she is liable, yes. If she followed policy and instructed the client to call pcp today, or called pcp office herself, and client was asymptomatic at time of visit, no she isn't liable as she has done exactly as her policy instructs. In cases were clients are not reliable to call, yes the nurse calls. Or calls the dpoa or power of attorny.

I work in home care and the reality is that we are faced with this type of thing all the time. Someone whose not quite as good as they could be, who has somethinh goig on. You call the doctor, you speak frankly to the client what you think is going on and make your reccomendation, then leave. We do not transport, if the client is alert and oriented we do not call 911 unless they agree. I had a gentlemen having chest pain, very obvious CHF and it took me nearly half an hour to convince hime to let me call 911. I have had clients with obvious cellulitis, pneumonia etc that refuse my reccomendation they go to see the doctor. I chart and leave. I can't control what they do. I can only make a reccomendation based on what I see and know and chart my efforts. You will always have people who refuse reasonable care. Thats life.

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If there is a policy in place of what to do with abnormals than no, I don't think a nurse would have to call 911 for asymptomatic abnormals.

If the nurse left a client with a clearly high blood preassure she is liable, yes. If she followed policy and instructed the client to call pcp today, or called pcp office herself, and client was asymptomatic at time of visit, no she isn't liable as she has done exactly as her policy instructs. In cases were clients are not reliable to call, yes the nurse calls. Or calls the dpoa or power of attorny.

I work in home care and the reality is that we are faced with this type of thing all the time. Someone whose not quite as good as they could be, who has somethinh goig on. You call the doctor, you speak frankly to the client what you think is going on and make your reccomendation, then leave. We do not transport, if the client is alert and oriented we do not call 911 unless they agree. I had a gentlemen having chest pain, very obvious CHF and it took me nearly half an hour to convince hime to let me call 911. I have had clients with obvious cellulitis, pneumonia etc that refuse my reccomendation they go to see the doctor. I chart and leave. I can't control what they do. I can only make a reccomendation based on what I see and know and chart my efforts. You will always have people who refuse reasonable care. Thats life.

That's what I was getting at, there needs to be a policy.

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