Workplace Policies May Not Match Legal Requirements, But You Still Need to Adhere

By Melanie Balestra, NP, Esq.

Recently I received a question from a Nurse Practitioner concerning what to document when referring a patient to a consulting physician. The physicians were telling the NPs not to document that they were referring the patient to a particular physician because it increases the physician’s liability.

This simply is not true. You protect yourself and the patient when you document that you spoke with a physician and/or are referring the patient to a physician. This also assists in making sure that follow-up is done to make sure that the patient was referred. It also documents the reasons that you referred the patient to the physician and/or specialist.  This only increases the physician liability if the physician refuses and/or does not see the patient.

I cannot stress the importance of always documenting your care and referrals for the patient. If this occurs where you work, you need to have a meeting with the medical staff to explain the importance.

Another recent complaint is that the physician wants to review and co-sign all the charts. This is not required in California. You can explain this to your employer but if the facility wants to have this as their policy, you can only try to convince them not to.

The NP has to go by whatever policies their employer may have, whether or not required by law. So, before you start employment, you may want to check out employee policies for NPs first.

Melanie Balestra is both an attorney and a nurse practitioner. She is a former President of CANP, and is currently President of the American Association of Nurse Attorneys, which in 2016 honored her with the award for Outstanding Health Law & Compliance Section Member. She has law offices in Irvine and Newport Beach, and continues to work part time as a PNP and Director of Pediatrics at the Laguna Beach Community Clinic.