Frequently asked questions regarding RN Employed Personnel Practice at PCMH.

1. Is it permissible for a registered nurse to document a history and physical, medical plan of care plan of care, discharge summary, progress notes, and other entries for a physician when these entries in the hospital medical record are narrated by the physician in the presence of the registered nurse?
   

   If the history and physical is the admission medical history and physical, the registered nurse may document what the physician tells the RN as the physician is performing the history and physical exam on the patient. The registered nurse may only record the medical plan of care as stated by the Physician.

   In documenting the medical history and physical and the medical plan of care as stated by the physician, the registered nurse is performing a secretarial function for the physician. The information can be recorded in the progress notes and signature is recorded as: "dictated by Susan Smith, RN for Dr. Brown."

   The registered nurse is only recording the information for the physician. The registered nurse may not prescribe a medical treatment regimen or make a medical diagnosis unless she/he is a nurse practitioner. The registered nurse could gather demographic information, allergies, past medical history and surgeries for the physician, but the signature after documentation of this information would be "Susan Smith, RN" so it is clear that the information was obtained and documented by the registered nurse.

2. Is it permissible for the nurse recording a history and physical exam to use portions of other medical records (e.g. office records) to supplement the information directly communicated to the nurse by the physician on the day of admission?
   
   Yes, that is permissible as long as it is clear in the registered nurse's signature that this is information obtained from the medical record that has been completed by the physician.

3. Is it permissible for a registered nurse to pull together information from the medical record in order to dictate a discharge summary that will later be reviewed and validated by the attending physician? If so, how should the nurse sign the transcribed discharge summary?
   
   Yes, this is permissible for the registered nurse to do as she/he is performing a secretarial function for the physician as described in question 1. The registered nurse would sign his/her name as "Susan Smith, RN, dictated for Dr. Brown."

4. Is it permissible for a registered nurse to actually perform the admission history and physical for and on behalf of her employer, a physician licensed to practice medicine in this state? If so, does the physician need to be present during the examination?
   
   No, if this is a medical admission history and physical exam, a registered nurse cannot perform an admission medical history and physical. If this is a nursing admissions history and assessment then a registered nurse may obtain it and follow-up with a nursing diagnosis and care plan. Registered nurses who perform nursing histories and assessments are employees of the hospital, and the registered nurses who are employed by physicians, are held to the same scope of practice. Performing a medical admission history and physical is not within nursing law and rules for the registered nurse. Nurse practitioners approved to practice by the Joint Subcommittee of the Board of Nursing and the Medical Board can provide admission medical history and physicals, provided this activity is covered in the protocols that are developed between the nurse practitioner and primary supervising physician.

5. Is it permissible for a registered nurse to direct patient care with respect to an inpatient in a hospital setting utilizing physician approved standing orders or protocols without physician being physicallypresent or directly selecting the appropriate protocol or order?
   
   Yes, the registered nurse, as well as the licensed practical nurse, can use protocols that end in standing orders that are reviewed periodically, revised whenever the practice changes, and signed and dated by the physician. The format attached is to be used. Copies of standing orders to be submitted and reviewed for approval by PCMH Patient Care Services Vice President once a year and with each changes/revisions that may occur.

6. May a registered nurse who is employed by an attending physician (but independent of the hospital) administer medications to patients in the hospital setting that are ordered by the attending?

Yes, if the registered nurse has submitted a request to practice form that indicates the medication requested to be administered. The practice form request must be approved by Patient Care Administration before such medication can be administered. The registered nurse must also continue to function within his/her scope of practice, adhere to all other applicable hospital policies and procedures and have the knowledge, skill and competency necessary to administer the medication.