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Nursing Diagnosis

Nursing diagnosis is a term that has come into use in recent years through nursing education. It has physicians confused and some health care attorneys concerned. For the most part, making a diagnosis is an act of medical judgment that may be done only by a licensed physician. From the risk management standpoint, it may be wise not to use the term. There are some types of diagnosis that a nurse may do independently--for example, wound care. A nurse does not need the authorization of a physician to diagnose a superficial abrasion of the knee. The nurse is doing the same thing a physician would be doing, and it is not necessary to qualify the term as a nursing diagnosis.

The term and the concept of nursing diagnosis have no place in an outpatient medical record. Typically, chart entries are made by physicians and nurses in the same set of progress notes. Any use of the term diagnosis will be perceived as a true diagnosis in the medical sense. A nurse making a diagnosis must be working under strict protocol or direct supervision of a physician. Any other diagnosis made by a nurse constitutes the unauthorized practice of medicine.

The term nursing diagnosis is often used as the title of a nursing care plan. This is confusing but legally acceptable if the nurse is not making a diagnosis or ordering care. Problems arise when the nurse fails to understand the difference and writes a medical diagnosis on a patient. As an example, a patient admitted to a hospital with a physician's diagnosis of congestive heart failure might have a nursing diagnosis of "complete bed rest for congestive heart failure." This compliments the physician's diagnosis and order for bed rest and does not lead to confusion.

If the physician has admitted the patient with a diagnosis of "rule out congestive heart failure, rule out renal failure," and the nursing diagnosis is "complete bed rest for congestive heart failure," then the nursing diagnosis can be revised in response to the change in the medical diagnosis. If, however, the nursing diagnosis is recorded as "congestive heart failure," the nursing notes and the physician's problem sheet are in conflict, and the patient's care may suffer. Other physicians and nurses caring for the patient will be treating the patient for the wrong problem if they rely on the nursing diagnosis.


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