NY Scope of Practice for Nurses The scope of nursing for nurses is largely similar but differs across states because of different practice environments. The variance is nursing scope of practice across states is also attributable to the differences in nurse practice laws and regulations. Actually, each state has established specific laws and regulations that govern practice within the state. These laws incorporate different licensure and regulatory requirements as well as details regarding nursing practice environment. Some examples of states with different scope of practice for nurses are New York and California. The differences in the scope of practices in these states are evident in definition of some aspects of nursing such as definition of standing orders, developing workflows in electronic health records, and what nurses can order in the EHR.

Definition of Standing Orders

One of the major ways in which nursing practice differs between New York and California is definition of standing orders. Standing orders are generally defined as prewritten medication orders and specific directions provided by the licensed independent practitioner to administer medication to a patient/individual whose condition has been clearly identified (Buppert, 2012). Generally, nurses work in collaboration with physicians to create a series of standing orders to help provide safe and efficient care. Therefore, standing orders are created and approved by physicians since they are responsible for care delivery covered by the orders.

Based on New York State's scope of practice for registered nurses, standing orders are defined as non-patient specific medical orders that are used to direct nursing care (New York State Education Department, 2009). However, according to the State Education Department, standing orders are considered inappropriate since creating a medical treatment plan is difficult and potentially dangerous without a relationship between the patient and an authorized care provider. This is primarily because of the complexities of individual's co-morbidities, significant allergies, several medications, and challenges in creating a one-size-fits-all treatment plan. Nonetheless, the New York State Legislature established certain criteria for the non-patient specific standing order as a legitimate entity in 2000.

In contrast, the California scope of practice for registered nurses define standing orders as written orders that are utilized when a specific order for a specific patient offered by a licensed health care provider within his/her professional scope of licensure or practice. In this state, physicians can utilize standing orders to authorize nurse practitioners or medical assistants to offer certain services. However, the use of these orders by medical assistants and licensed practical nurses is restricted and based on specific nursing rules and settings.

In light of these differences in definitions, there are variances in what a registered nurse may order on his/her own behalf in New York and California. In New York, a nurse may order for the administration of immunization, provision and administration of antianaphylactic agents, and delivery of purified protein derivative (PPD) tests and HIV tests (Buppert, 2012). On the contrary, nurses in California may use standing orders to order for administration of medication/drugs and initiation of clearly described clinical processes to a specific patient.

Designing Workflows in Electronic Health Record

The other aspect in which nursing practice differs between New York and California is the implications when designing workflows in the electronic health record using computerized order entry. Computerized order entry is generally described as direct entry of clinical orders into the electronic health record of a healthcare system by licensed independent practitioners or medical staff with certain ordering privileges. The entries are not made by clinical or administrative support staff because they do not have ordering privileges.

In California, the implications of designing workflows in electronic health record using computerized order entry include issues that have traditionally been regarded as barriers to the adoption of these applications in healthcare practice. These barriers include poor planning and implementation, lack of adequate participation by clinicians, lack of standardized medical terminology, and insufficient financial commitment (Doolan & Bates, 2002, p.183). Nonetheless, the implications of designing workflows in electronic health record using computerized order entry include enhanced accuracy and completeness, reduced transcription, and capability to enter orders in several locations.

New York nurses also have similar implications when designing workflows in the electronic health record using computerized order entry. These implications emerge from the fact that computerized order entry has numerous advantages over paper-based techniques. Moreover, the use of these entries in designing workflows helps in enabling physicians to have decision support at the point of care. Decision support in turn lessens the rate of medication error and increases the suitability and cost-effectiveness of ordering medications and tests.

EHR Orders by Nurses, Physicians, and Mid-level Providers

Electronic health records have become common in today's healthcare setting and environment because of the shift from paper-based methods to computerized systems. These computerized records contain patients' health information like medical history, laboratory test results, allergies, payment, and radiology images. Based on...

This is achieved through the use of computerized physician order entry and electronic prescribing in electronic health records. In essence, physicians in New York can electronically order laboratory tests and diagnostic images in electronic health records. Moreover, physicians can order patients' medical histories since the basic medical charting system in these records captures patients' demographic data, hospital visits, and vital signs or medical conditions (The New York City Department of Health and Mental Hygiene, 2007, p.3). On the contrary, nurses in New York can order billing information, schedule appointments in electronic health records, and medication data. This is primarily because patients are involved in conducting administrative functions that like scheduling appointments to help in effective delivery of safe and efficient patient care. Mid-level providers in New York can order and receive medical information, lab tests, drug prescriptions or medication, and diagnostic images in electronic health records.
In California, physicians can order similar data to their counterparts in New York State i.e. patients' medical information/history, medications, laboratory, and diagnostic tests using alerts, prompts, and dynamic lists. This is primarily because physicians in this state are increasingly likely to have EHRs with functions that focus on individual patient visits instead of those that emphasize overall quality improvement (Coffman, 2012). On the other hand, nurses can order medication information, administration of medication, and patient histories while mid-level providers can order laboratory and diagnostic test results and information on medication.

In conclusion, New York and California have significant differences in scope of practice for registered nurses. The differences are attributable to the variances in state laws and regulations on nursing practice as well as differences in nurse practice settings and environment. Some of the major areas in which these states differ in relation to the scope of practice for registered nurses include definition and use of standing orders as well as the use of electronic health records by physicians, nurses, and mid-level providers.

New York vs. California Nursing Scope of Practice

Nursing Aspect

New York

California

Definition of Standing Orders

Non-patient specific medical orders that are used to direct nursing care.

Written orders that are utilized when a specific order for a specific patient offered by a licensed health care provider within his/her professional scope of licensure or practice.

What a nurse may order in his/her own behalf.

Administration of immunization, provision and administration of antianaphylactic agents, and delivery of purified protein derivative (PPD) tests and HIV tests.

Administration of medication/drugs and initiation of clearly described clinical processes to a specific patient.

Designing workflows in the electronic health record using computerized order entry.

Enhanced accuracy and completeness, reduced transcription, capability to enter orders in several locations, and physician access to decision support at the point of care.

Enhanced accuracy and completeness, reduced transcription, and capability to enter orders in several locations.

What can be ordered in electronic health records?

Physicians

Patients' medical histories, medications, laboratory, and diagnostic tests using alerts, prompts, and dynamic lists.

Nurses

Billing information, schedule appointments in electronic health records, and medication data.

Mid-level Providers

Medical information, lab tests, drug prescriptions or medication, and diagnostic images.

Physicians

Patients' medical information/history, medications, laboratory, and diagnostic tests using alerts, prompts, and dynamic lists.

Nurses

Medication information, administration of medication, and patient histories.

Mid-level Providers

Laboratory and diagnostic test results and information of medication.