RN Working Under Standing Orders

[HealthCenterDirector]

I am the director for a university health center that is looking to expand its patient volume. A large percentage of our patients come in for routine illnesses and injuries. I am considering the exploration of an arrangement where we use an RN to see these types of patients and treat them under standing orders/protocols.

I am specifically looking for the reference to applicable guidelines and regulations as well as comments and suggestions related to this type of arrangement.

Thanks

[Reno1978, BSN, RN]

My thoughts would be that you would still need to use a provider with prescriptive authority and the ability to diagnose medical conditions (MD, Nurse Practitioner, Physician Assistant).

It is not under a Registered Nurse's scope of practice to medically diagnose and prescribe treatment whether there are standing orders or protocols or not. An appropriate medical professional, not a RN, would still have to assess the patient to initiate standing orders, in my opinion.

[Neveranurseagain, RN]

You need to employee nurse practitioners or physician assistants to evaluate these pts. RN cannot diagnosis, and this is what this amounts to. Insurance companies would not reimburse either for these visits either. Check with your state board of nursing for guidelines of standing orders.

[tri-rn]

During nursing school we spent a day with a jail nurse. She operated under a similar arrangement. Her protocols included symptoms, so she wasn't actually diagnosing....IOW, if an inmate came in with XYZ symptoms, but without AB and C, then the RN would follow protocol H.

Hope the alphabet soup wasn't too confusing.

[Neveranurseagain, RN]

During nursing school we spent a day with a jail nurse. She operated under a similar arrangement. Her protocols included symptoms, so she wasn't actually diagnosing....IOW, if an inmate came in with XYZ symptoms, but without AB and C, then the RN would follow protocol H.

Hope the alphabet soup wasn't too confusing.

Good point! But were they billing insurance companies for MD visits? I have a feeling if insurance companies found out they would not pay for the visit.

[Thornbird]

Most University Health Centers employ Nurse Practitioners as RN's cannot diagnose. What your state says specifically about nurses and standing orders can be obtained from the Board of Nursing. These kinds of rules vary from state to state.

Prison/jail inmates health care is the responsibility of the state. (They are the only Americans with an absolute right to health care) There is normally no issue with insurance billing. Standing orders for the nurses are routine since there is not always a doctor on duty. It works pretty much like the prn orders in LTC. For problems not covered by the protocols, the nurse contacts the doctor as they would in other situations.

[HealthCenterDirector]

During nursing school we spent a day with a jail nurse. She operated under a similar arrangement. Her protocols included symptoms, so she wasn't actually diagnosing....IOW, if an inmate came in with XYZ symptoms, but without AB and C, then the RN would follow protocol H.

Hope the alphabet soup wasn't too confusing.

No, it is not confusing. In fact, that sort of arrangement is exactly what we are wanting to explore. I am fairly confident that it is permissible in Texas although I cannot quote chapter and verse. That is the reason that I wanted to inquire here.

[Neveranurseagain, RN]

You may want to check with Medicare and your contracted insurance companies first. My understanding (and I'm not a coding expert!)is that a MD has to exam the pt.to bill an E&M code. Now some providers do charge a "nurse" E & M code for a nursing encounter, but it may be called into question for sick or routine visits.

http://www.aamc.org/advocacy/library/teachphys/phys0001.htm

http://www.cms.hhs.gov/MLNProducts/Downloads/eval_mgmt_serv_guide.pdf

There is no way that an RN could perform this type of a exam/documentation needed to bill an insurance company or Medicare.

Why not just hire a Nurse Practioner or PA? This type of practioners would fit your need. I hope this doesn't sound rude but it sounds like you are trying to make a buck off of an RN.

[HealthCenterDirector]

You may want to check with Medicare and your contracted insurance companies first. My understanding (and I'm not a coding expert!)is that a MD has to exam the pt.to bill an E&M code. Now some providers do charge a "nurse" E & M code for a nursing encounter, but it may be called into question for sick or routine visits.

http://www.aamc.org/advocacy/library/teachphys/phys0001.htm

http://www.cms.hhs.gov/MLNProducts/Downloads/eval_mgmt_serv_guide.pdf

There is no way that an RN could perform this type of a exam/documentation needed to bill an insurance company or Medicare.

Why not just hire a Nurse Practioner or PA? This type of practioners would fit your need. I hope this doesn't sound rude but it sounds like you are trying to make a buck off of an RN.

It does sound rude and beyond the context of my original post.

In my original post, I stated that we are a university health center. University health centers do not operate to make "bucks", but we must use the ones that are allocated to us in an efficient manner. Hence my desire to explore such an arrangement.

Insurance billing is not an issue for us given that there is no charge for an office visit. Without getting into our business model, we do not file traditional insurance.

We do employ a Nurse Practitioner, a PA, and a M.D. and desire to explore said arrangement to increase our patient volume in the most efficient manner. In fact many of our patients would be well served under this arrangement given the simplicity of their conditions. I just wanted to get feedback from someone who had first-hand knowledge of or experience in such an arrangement.

[Neveranurseagain, RN]

You might check your local public health dept also. When I worked there we had standing orders to issue BCP's (after the pt filled out a questioner) to returning pt's under standing orders. But the first visit had to be with an MD then returning ones with a RN. This arrangement also worked with the STD clinic, pregnancy and Travel Immunitization clinic as well as Infectious Diseases.

I didn't want to come off as being rude but I've seen several MD offices who wanted RN's to "see" pts under standing orders when they should have actually hired a NA/NP--something you have already done. And with no insurance involved, it makes it easier. Check with your state board of nursing to see their take on the issue. I hope your what ever your arrangement is works out well!

[Batman24]

I'd call the BON and see what they have to say. Given the set up of your facility you might have some leeway. I'd check just to cover your employer and employees from a legal perspective.