treatment depth

[MurseNurse]

So I am having a bit of a struggle at work. I work in a clinic that sees patients with injuries. We often communicate injury status to their work which is protected transfer if information under workers compensation. I was basically told that my communication is too detailed and that I need to step it down. I was told that I am diagnosing the patient by saying (example) "this patient shows symptoms consistent with potential xxxxxxx". I was trained that this, with a strong supporting assessment, is good documentation.

Now, don't take this wrong, but I am pretty smart. I have great assessment skills. If I find a potential problem with a patient and forward the assessment info on to a NP or MD, I often put " It seems the patient is demonstrating symptoms consistent with xxxxx".

Now, I understand that a lot of what I'm being told is risk management from my supervisor, but I relish the fact that I know my stuff and can put symptoms together and identify a problem. Apparently, its fine for me to do that but not to communicate it. But if that's the case, what's the point? I really feel my spirit being killed now. I've been happy with this job until today.

I guess I just support nurses being more than what they have been traditionally. I don't feel that I am diagnosing patients. I feel that I am contributing to the health and well being of my patient in a manner that is more than just passing some meds.

Basically, am I being over zealous in my treatment? I can take the criticism if I am. Maybe I do need to tone back... What are your opinions in the matter?

[macawake, MSN]

I personally really enjoy the detective part of medicine. I love to try to figure out what's going on with my patient. It's satisfying to be able to "connect the dots" based on patient history, my assessment of the patient, lab/test results etc. and arrive at the correct diagnosis.

But....

I'm not a physician, I'm a nurse. So I will never chart something along the lines of: my assessment suggests this particular medical diagnosis. Even if I'm convinced that this is what the patient suffers from. It's not my job. I will however report my observations and assessment to the physician.

When I inform the physicians I work with about my observations/patient assessment they almost always ask for and seem to value my input. If I happen to work with one of the very few snarky ones, I will offer my thoughts on the matter even if they don't ask for it, if I feel that this is vital for the patient. That almost never happens though.

I've had many interesting discussions with my physician coworkers about specific cases and I keep learning new things, and I try to further improve my "medical detecting skills".

I attend university courses pretty much every semester, I read a lot of medical journals and research to improve my knowledge base. So, I really do understand where you're coming from but I do think you need to stop charting the way you do. It's not in a nurse's scope (and I'm guessing that fact alone can get you into trouble?) plus your supervisor/employer has told you to stop.

I think it's a bit odd that you were trained to chart medical diagnoses. I'm not an American nurse, so I'm educated and work in another country. But I think that we share the same scope of practice at least in this matter?

My advice to you is change your habits regarding charting/written communication but by all means don't stop trying to figure out what's going on with your patient.

[classicdame, MSN, EdD]

this points out one plus of electronic documentation. We just answer the questions and then move on. Too much information muddies the waters and people are not that impressed anyway.