Using medical terminology as a nurse

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Hi guys, so I’m a new LVN/LPN.. I did a COC on one of my patients d/t having blood in her urine. My DON just informed me that I wasn’t allowed to use the word “Hematuria” because I’m not a doctor or NP so I’m not allowed to “diagnose”. Is that true? I thought Hematuria just meant blood in urine. Didn’t know it was a diagnosis. Hope you guys can clear this up for me. Because I have been using the word Hematuria for a lot of my charting esp the ones on monitoring for UTI. Thank you!

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Specializes in Surgical, quality,management.

What is a COC? https://www.abbreviations.com/COC as you can see there is 4 pages of definitions.

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I believe COC is change in condition. OP, you are right in that it means blood in the urine. It would not be wrong for you to call and say a patient is having gross hematuria if that is the case as that most accurately describes the change.

Technically it can be billed as a diagnosis, but so can a lot of symptoms, including cough and fever, to allow providers to bill a note before they have a concrete diagnosis. It would not be inappropriate or out of scope to chart the word as a LVN or RN.

However, I'd recommend avoiding the word (even though you are right and it is annoying that you have to) to maintain a good relationship with your employer.

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Specializes in ER OR LTC Code Blue Trauma Dog.

Did a urine strip record and confirm a high presence of RBC's in the urine?

I mean how do you know it's Hematuria and not something else like the beets they had for lunch?

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Specializes in Surgical, quality,management.
3 hours ago, Crash_Cart said:

Did a urine strip record and confirm a high presence of RBC's in the urine?

I mean how do you know it's Hematuria and not something else like the beets they had for lunch?

Or PV loss?

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Specializes in ER OR LTC Code Blue Trauma Dog.
15 minutes ago, K+MgSO4 said:

Or PV loss?

Or perhaps the pt. has been taking the medication Rifampin?

I guess my entire point is you can't readily conclude it's "Hematuria" without evaluating the bigger picture of things.

"Appearances" are not a definitive conclusion of anything.

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@Crash_Cart - fair point. I am curious how you would describe this finding, though.

"Red substance noted in brief" (?)

"Pink color on tissue paper after wiping" (?)

"Red moisture noted in peri area after pt urinated" (?)

I suppose (at least if this is LTC) it is a simple matter to know basically whether beets have been on the menu in the last number of days, and very easy to rule out Rifampin as the culprit.

Sometimes failing to use language that would commonly be understood as conveying the situation or concern does nothing but confound the issue and delay appropriate care. The goal in this case would be to be able to obtain a urinalysis.

I would probably cover both bases and document something like "Concern for gross hematuria:" and then one of the more descriptive statements I wrote above. That describes both the finding and my concern about it, which I think is the best overall idea.

6 hours ago, egg122 NP said:

However, I'd recommend avoiding the word (even though you are right and it is annoying that you have to) to maintain a good relationship with your employer.

This is almost never a blanket good reason for patient care related/professional decision-making. IMHO. There are too many dingbats involved. This DON could have had a bona fide debatable point if she had mentioned Crash_Cart's rationale, but instead she just doesn't know what she is talking about.

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I don’t see hematuria as a diagnosis. The diagnosis is what is causing the hematuria.

It doesn’t matter if you say blood in urine or hematuria, they are the exact same thing.

Now, is it actually hematuria based off of testing or did you suspect it? My guess would be your DON doesn’t want you stating something you haven’t confirmed yet. And were you telling the pt this or just describing it in a note?

Its like me saying a pt is febrile. I’m not diagnosing a thing. The fever is a symptom of something else.

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3 hours ago, JKL33 said:

"This is almost never a blanket good reason for patient care related/professional decision-making."

Patient care related decision making is not being changed but not using the word hematuria. If I received a call stating the patient's urine is red, the urine is bloody, or it looks like there is blood in the urine, it would lead to the same orders being issued as if the person stated that the patient has hematuria. Having walked from 5 jobs in 10 years due to actual patient care issues, I feel this is not a hill to die on with an employer given not using the word hematuria:

1. Does not negatively impact the patient outcome or care

2. is not unethical

3. is not illegal.

Given the number of times we see those three scenarios in healthcare, it is important to know when to pick and choose battles. Personally, I'd save mine for ones that meet the above 3 criteria.

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Specializes in Psychiatry, Community, Nurse Manager, hospice.

You didn't really do anything wrong. You didn't make a medical diagnosis.

Not saying you shouldn't do it her way. Or that you should. Just that she's wrong.

I'm diagnosing her with wrongness of opinion, and I'm not an NP. Call the board!

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18 hours ago, Crash_Cart said:

Did a urine strip record and confirm a high presence of RBC's in the urine?

I mean how do you know it's Hematuria and not something else like the beets they had for lunch?

Ahhh you’re right. So in that case we would document that urine was red in color?

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12 hours ago, JKL33 said:

@Crash_Cart - fair point. I am curious how you would describe this finding, though.

"Red substance noted in brief" (?)

"Pink color on tissue paper after wiping" (?)

"Red moisture noted in peri area after pt urinated" (?)

I suppose (at least if this is LTC) it is a simple matter to know basically whether beets have been on the menu in the last number of days, and very easy to rule out Rifampin as the culprit.

Sometimes failing to use language that would commonly be understood as conveying the situation or concern does nothing but confound the issue and delay appropriate care. The goal in this case would be to be able to obtain a urinalysis.

I would probably cover both bases and document something like "Concern for gross hematuria:" and then one of the more descriptive statements I wrote above. That describes both the finding and my concern about it, which I think is the best overall idea.

This is almost never a blanket good reason for patient care related/professional decision-making. IMHO. There are too many dingbats involved. This DON could have had a bona fide debatable point if she had mentioned Crash_Cart's rationale, but instead she just doesn't know what she is talking about.

Hahaha “red substance found in brief”... I can’t . Thank you for your response!

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