Today’s correspondent asks:

What is the scope of practice of paramedics, ED nurses, etc. to make a diagnosis? This is a general question, but particularly of concern if mental health is involved.  Isn’t diagnosis outside the scope of practice of both paramedics & nurses? Shouldn’t they just note symptoms, not diagnoses. What could the legal consequences be?

It’s hard to find concrete info on this issue. One thing found is a California nurse practice advisory that states: “”The Medical Practice Act authorizes physicians to diagnose mental and physical conditions, to use drugs in or upon human beings, to sever or penetrate the tissues of human beings and to use other methods in the treatment of diseases, injuries, deformities or other physical or mental conditions. As a general guide, the performance of any of these by a registered nurse requires a standardized procedure…”

Of course, California might be different from Australian states.

Yes ,California is different from Australia.  In Australia the Health Practitioner Regulation National Law does not define scope of practice.  It’s clear that paramedics ‘use drugs in or upon human beings, … sever or penetrate the tissues of human beings and … use other methods in the treatment of diseases, injuries … or other physical or mental conditions’.  And they don’t do that under the direction of a medical practitioner.   The California document is irrelevant.

My correspondent gives an example.  Although I don’t give legal advice on particular issues and nothing written here can be used to infer whether the practitioners’ actions were lawful or not, I will repeat it to explain the point. My correspondent says:

Paramedics were called out, looked and saw that the patient’s doctor had prescribed anti-psychotics. The paramedics then wrongly assumed the patient had schizophrenia and was suicidal. The ED nurse documented this false diagnosis.

They were wrong, but even if they were right, isn’t such a diagnosis outside the scope of practice of both paramedics & nurses? Shouldn’t they just note symptoms, not diagnoses. In the example, shouldn’t they just have noted the medication they found at the patient’s place, the patient behaviour they directly observed, and nothing more? What could the legal consequences be?

Diagnosis means:

  • ‘The identification of the nature of an illness or other problem by examination of the symptoms’ (Oxford English Dictionary (Online));
  • ‘a judgment about what a particular illness or problem is, made after examining it’ (Cambridge English Dictionary (Online));
  • ‘the discovery and naming of what is wrong with someone who is ill or with something that is not working properly’ (Collins English Dictionary (Online)).

A diagnosis is an opinion formed from the evidence available.  It may be right or wrong and it may be made with more less confidence. Everyone makes a diagnosis. Your child comes home with a runny nose and a fever and you diagnose a cold and put them to bed, or meningitis and you take them to hospital.

Paramedics and nurses have to make a diagnosis based on the patient’s signs, symptoms and history in order to make a decision as to what to do next.  When they find a person unconscious they have to ‘diagnose’ why they are unconscious – is it hypoglycaemia or a drug overdose as the treatment they will initiate will be very different.

The degree of confidence and detail required will vary with what a person might do.  As a layperson I may diagnose that the person collapsed in front of me has had a cardiac arrest and commence CPR.  Paramedics will determine the nature of their cardiac rhythm and other matters necessary to inform their treatment.  At that point their concern is to try and keep the patient alive and hopefully get a return of spontaneous circulation.

In hospital doctors may want to diagnose whether the cardiac arrhythmia is due to an electrical issue in the heart or a chemical issue to determine whether a pacemaker or drug therapy is required to reduce the risk of the event happening again.  Everyone is making a diagnosis though with different degrees of confidence and detail.

With respect to mental illness a psychiatrist’s diagnosis is required to authorise involuntary detention and treatment. In most states and territories mental health legislation allows paramedics to treat a person even if they do not consent if the person appears to be mentally ill.  Because diagnosis of mental illness is not something that can be done in the field all that is required is a belief, usually upon reasonable grounds, that the person is suffering from a mental illness (see for example Mental Health Act 2007 (NSW) s 20).   A determination that a person ‘appears to be mentally ill or mentally disturbed’ is not the same as forming a conclusion, or diagnosis, that they are mentally ill.

With respect to the example given, my correspondent implies that the conclusion that the patient was suffering ‘schizophrenia and was suicidal’ was based solely on the observation that the ‘patient’s doctor had prescribed anti-psychotics’.  We don’t know what else the paramedics observed or what conversation they had.  The mere fact I’m asked this question demonstrates the value there is in recording, in as much detail as possible, ‘the medication they found at the patient’s place, the patient behaviour they directly observed’ and anything else relevant to support their belief that the patient required treatment.  That is particularly important where the paramedics propose to detain the person under relevant mental health legislation.

The paramedics or nurses however may be quite certain and so express their view as ‘patient suffering from schizophrenia and is suicidal’ and one might say that is a diagnosis. The legal consequences of that are … nothing at all.  Whether the paramedics believe and record that ‘the patient is suffering from schizophrenia’ instead of ‘I formed the view that the patient is suffering from schizophrenia’ is going to make no difference.  If the paramedic has a ‘reasonable belief’ that the criteria for detention under the mental health Act in their jurisdiction has been met, then the patient can be detained.  If there is a challenge to their decision making eg the patient sues for false imprisonment, they will have to justify the basis for their belief based on, as noted, the things and behaviours observed.  How the final opinion was expressed on the patient record will be irrelevant.

Equally if the patient is taken to a mental health institution it will be up to a psychiatrist to examine the patient and determine whether the patient is mentally ill and the other criteria for involuntary detention have been met.  The opinion of the paramedics may justify the initial detention (to again use NSW as the exemplar, see Mental Health Act 2007 (NSW) s 18) but it will not impact upon the psychiatrist’s assessment.

Conclusion

The paramedics diagnosis explains why they took the action they did but it doesn’t prove that they were right.  The fact that I’m asked this question demonstrates the sensitivity of the issue, people don’t like being labelled or having their loved ones labelled so it may be prudent to avoid writing a firm conclusion.  But it’s not illegal for paramedics or nurses to make a diagnosis, they do it every day of the week.  The difference between a doctor’s diagnosis and a paramedics or a nurses is that most people won’t accept the paramedic or nurses diagnosis as definitive.   We look to medical practitioners to write the experts reports and to confirm that the patient ‘is’ suffering from a particular condition and to arrange ongoing care.  But just because the doctor makes the ‘definitive’ diagnosis it does not guarantee that they are correct.