Why doctors never write diagnosis for their prescribed pills?

[Leonardo Del Toro, RN]

Every time I get orders for a facility transfer, I rarely see diagnosis for the orders. But we must enter one. Since there is none valid we'll come up with one, but just to get yelled at for picking a wrong one. MD's out there, can you please enter your frigging diagnosis? And by the way, buy a calligraphy book too, because you how to write legibly. 

[amoLucia]

You aren't asking for too much .... :)

[Closed Account 12345]

The clinical rationale isn't routinely part of a physician's order (barring exceptions like PRN meds, sliding scale, etc.).  This is why nurses must ask themselves if an order is safe and makes sense for a patient before carrying it out.  

The medication/diagnosis requirement, while helpful, sounds more like an organizational policy by your employer. I'd bring your concerns to admin, letting them know that it's not within your scope to assign medical diagnoses in the chart.  Sometimes there isn't an obvious diagnosis for a medication; it may have an off-label use or be an adjunct. Sometimes meds are strictly preventive and not the result of an existing medical diagnosis. Sometimes orders are just related to a procedure, not a diagnosis. I would request an option for the diagnosis of "Unknown" or "Not Provided."

If your administration isn't willing to make this allowance, and providers are upset with how things are done (after failing to enter their orders in accordance with your facility's policy), I'd start calling the doctor every single time. Why is Mrs. Jones getting vitamin D? Why is Mrs. Jones getting albuterol? The squeaky wheel gets the grease, and I imagine the providers would get squeaky pretty quickly. 

[Tweety, BSN, RN]

I think the SNF's and LTC's here require a diagnosis for most medications (I notice on the med sheets they provide us when they send us patients, almost every med says what it's for), especially antibiotics, they want to know what it's for and what is the duration.  Often MD's fail to provide this.  Still most of us that have cared for the patient would know the diagnosis but it's not for us to decide the duration and I call to clarify that.

 

[Leonardo Del Toro, RN]

On 9/3/2021 at 7:15 PM, Tweety said:

I think the SNF's and LTC's here require a diagnosis for most medications (I notice on the med sheets they provide us when they send us patients, almost every med says what it's for), especially antibiotics, they want to know what it's for and what is the duration.  Often MD's fail to provide this.  Still most of us that have cared for the patient would know the diagnosis but it's not for us to decide the duration and I call to clarify that.

This is not a constant, and sometimes the diagnosis is clearly wrong. I've seen the same diagnosis being used for the entire list of meds...it is kind of a mess if you ask me.

[summertx]

22 hours ago, Leonardo Del Toro said:

Every time I get orders for a facility transfer, I rarely see diagnosis for the orders. But we must enter one. Since there is none valid we'll come up with one, but just to get yelled at for picking a wrong one. MD's out there, can you please enter your frigging diagnosis? And by the way, buy a calligraphy book too, because you how to write legibly. 

Some times the primary diagnosis, and co-morbidities will give clues. I.e. iron - anemia, B12- something neurological, seizures etc. In LTC we have to put one in, doc is no where to be found. MD's  aren't responsible for the patient when push comes to shove, what do they care. 

[hibiscus6, BSN]

It’s a regulation (at least in my state) in SNFs that every medication must have a diagnosis.  Since that regulation doesn’t apply in hospitals or other settings, both sides can become frustrated.  Hospitalists and other doctors aren’t used to being asked for diagnoses, and SNFs don’t want to get a citation for being out of compliance.  My facility has a form for follow up on questions re new admissions’ orders, including a section where we list each med needing a diagnosis.  We give this to the provider who is caring for them in our setting.  We are now lucky enough to have an in-house NP/MD team who see every patient, but before that we would fax it to the provider (and we got to know which providers would give the diagnosis, and which expected us to write in the likely diagnosis so they could just sign it).

[amoLucia]

Usually there's info in their progress SOAP type notes. And some places had a chart form for cumulative diagnoses. It was smack-dab in front of their progress notes page and we could flag it if nec. Docs just HAD TO address it.

You just have to know where to look. Of course that says those forms are avail for your review. Now how all that works with the electronic charting is ??? for me.

We were usually sticklers for diagnoses. NOCs usually had to complete lab requisitions nightly. We usually always needed diagnoses, and some places had us actually ICD coding. This was esp critical when we needed to monitor medication blood levels. (Now we had two codes to record.)

Now penmanship is prob harder to correct. :(