HIPPA and schools- Student rights

[jiminyC_fan]

As stated above, it has nothing to do about care. She wanted him to change his diagnosis. A school nurse should never, ever ask a doctor to change a diagnosis that a child has had for eight years.

 

[roseaster]

We posted at the same time, your post was not up.

Still, it is not a HIPAA violation. It was provider to provider communication. Whether what she asked for was "correct" or not, she did not violate HIPAA. If this was medical information given to her by the doctor and she had any question of concern it would be the physician she directly contacted. The physician gave her the medical info, assuming with his mother's permission, she questioned it. Whether she should have or not is a different story, but she did nothing wrong questioning it.

 

[jiminyC_fan]

We posted at the same time, your post was not up.

Still, it is not a HIPAA violation. It was provider to provider communication. Whether what she asked for was "correct" or not, she did not violate HIPAA. If this was medical information given to her by the doctor and she had any question of concern it would be the physician she directly contacted. The physician gave her the medical info, assuming with his mother's permission, she questioned it. Whether she should have or not is a different story, but she did nothing wrong questioning it.

Thanks for the explanation of posting at the same time. That definitely happens a lot. LOL

Asking to reword his diagnosis is wrong no matter what. It has remained the same for 8 years. He remains the same for 8 years. I think that is why I am questioning whether or not she had the right to contact him. It had nothing to do with care, period.

 

[roseaster]

Thanks for the explanation of posting at the same time. That definitely happens a lot. LOL

Asking to reword his diagnosis is wrong no matter what. It has remained the same for 8 years. He remains the same for 8 years. I think that is why I am questioning whether or not she had the right to contact him. It had nothing to do with care, period.

It still isn't a violation of HIPAA. She may have overstepped her bounds, but she didn't violate HIPAA by disclosing confidential medical information.

The only way it would be a HIPAA violation is that if she provided medical information to a 3rd party without permission. Permission, here, to discuss this medical information with this particular provider is implied in that the doctor gave HER the information.

Now, had she provided this information to another doctor, or a parent, or someone who was not in need of that information for the safety or care of your grandson, that would be a violation. Discussing the case with his doctor, and making suggestions, even if they are out of her scope of practice, isn't.

FWIW, and not that this applies to your grandson, this type of discussion goes on between doctors and nurses a lot. My example. I'm an APN in a partial care program for the mentally ill. In discussing a patient with a doctor I will say things like, "I see a lot of mood instability in John Doe, have you thought about trying a mood stabilizer?" or "I have seen a lot of mood instability in John Doe, have you thought that maybe his primary diagnosis may be more schizoaffective disorder than schizophrenia?"

I think the difference is that we work together, so he sees it as more of an observation or discussion than me telling him what to do. I interact more, and in a different way with the patients, so I may have an observation that he does not.

Again, not that this is your situation, just something to think about.

 

[The Mystery Machine]

Thanks for the explanation of posting at the same time. That definitely happens a lot. LOL

Asking to reword his diagnosis is wrong no matter what. It has remained the same for 8 years. He remains the same for 8 years. I think that is why I am questioning whether or not she had the right to contact him. It had nothing to do with care, period.

The nurse has the right to call the doctor about anything no matter how good or evil it is.

 

[jiminyC_fan]

I 100% understand your situation in a partial care program. You are having a hand in their care. I would only hope a nurse would step in and articulate her concerns. And again, you are right. It isn't the same as what is happening with us. She definitely over stepped her boundaries suggesting a different diagnosis. For goodness sake, Epilepsy is difficult even for the well seasoned doctors. No case is the same as another. What I admire from all of his doctors is that they admit that the parents probably know more about the condition than the doctor.

 

[roseaster]

I understand what you are saying, but please understand that it would not be appropriate to have that type of discussion with a parent.

She may have overstepped by asking the doc to change the diagnosis, or even suggesting a medication, of course, unless we heard the actual discussion and how it was worded, I can't say, but there would never be any circumstance where calling the parent to discuss a doctor's written records and your disagreement with them would be appropriate, unless the parent was the child's doctor.

If a nurse has a question about, or a disagreement with what a doctor wrote in a patient's chart he/she would never approach the patient and ask about it and ask the patient to relay it to the doc in question. That would be totally inappropriate.

The bottom line is that there was no violation here. You may not agree with what she did, but she didn't do anything wrong or actionable. Nurses have the right to question doctors. We are actually encouraged to do it if we feel that it is in the best interest of our patients. This kind of discussion happens daily. The difference is, normally, docs don't report to the patient, "nirse Betty questioned me."

 

[Pea-n-Me]

It is sometimes really hard to figure out exactly what's going on in posts like these. I am really not sure what is meant by the nurse tried to change the diagnosis or "definitely overstepped boundaries" when clearly people don't always even know what a nurse's role is, exactly. It seems to happen a lot in these medical type posts.

Roseaster gave a good example of how a health care team communicates. In my previous post I described it as a "dialogue". Long gone are the days that nurses followed doctor's orders blindly. Nurses today are an integral part of the care team who work in conjunction with other care team members, bringing our own set of established guidelines to the mix. Everyone brings something to the table, in other words. Nurses have their own scope of practice and own research-based interventions. Most people don't really understand what we do.

That said, you have to remember that school nursing is a specialty. You can look into the Association of School Nursing guidelines to see more, if you want. (Not sure exactly what the association is called.) Generally, school nurses will come to their positions with a lot of experience. All nurses also must "continue their education" via courses required every two years (may vary by state) to renew their licenses, and generally nurses will choose courses either in their specialty (some may be given on the job) or ones whose subject matter they enjoy. These continuing education units will educate the nurse to the most current information available - important when people have been out of school for a while, in any specialty. Some will have also worked in a specialization for years, perhaps, before they became a school nurse, often pediatrics in a specialty hospital, and often in a speciality like cardiology or neurology or nephrology or whatever.

So what I see as a possibility here is that the school nurse may have come across information that didn't quite jibe with what was perhaps outdated information in granson's medical record, and she wanted to clarify it; have a professional discussion about it; perhaps made suggestions for updated information, etc. To a non-medical person, and a parent, it could absolutely seem like the nurse was "trying to change things", when in fact, she may have been trying to make sure grandson benefitted from the latest information. I've found even in my own practice that people do tend to stick with old information that's "worked" for them, even if it' sold and/or outdated, and that's fine. Heck, I've done it myself. But having a discussion like this doesn't mean the nurse was trying to "change a diagnosis", necessarily. My suggestion would be for your daughter to sit down with the nurse and just say "I was wondering what's going on", and let the nurse explain it. Hopefully your daughter will then just see that the nurse is simply being an advocate for her son, and maybe they can have a better relationship going forward once everyone is on the same page.

 

[Pea-n-Me]

I often ask patients what their understanding of things is. It helps me know where they're coming from. If it happens to differ from what the plan of care is as I know it, then I work to bring the information together in a way that everyone can be comfortable with. It differs in every situation, but rare is it that we can't all work it out.

I'm getting the sense here that there is a dislike/distrust of the school nurse and that is part of the problem here.

 

[roseaster]

I often ask patients what their understanding of things is. It helps me know where they're coming from. If it happens to differ from what the plan of care is as I know it, then I work to bring the information together in a way that everyone can be comfortable with. It differs in every situation, but rare is it that we can't all work it out.

I'm getting the sense here that there is a dislike/distrust of the school nurse and that is part of the problem here.

I get that feeling, too. I guess my bottom line is, and I was trying to give it by way of an explanation is that, even though the OP does not agree with what the school nurse did, there was no HIPAA violation and nothing actionable was done.

 

[aejammers]

I feel like I need to jump in here in defense of the OP. My DS had the same type of epilepsy as the OPs. It is very rare. 100s of seizures a day of all types of seizures. In my experience, most neurologists don't know what it is or have ever had a patient with this type of epilepsy. So it is doubtful that the nurse has ever experienced this before.

In fact, one of the doctors we saw before my DS was diagnosed was fixated on the fact that my DS wasn't speaking very much (he was 2) so she brushed off the seizures. She was convinced he had autism and wanted to focus on that and not on the seizures. And this was at a very well-respected children's hospital. (BTW, he does not have autism.)

And since this is such a rare syndrome (really, google Doose syndrome, or Myoclonic-Astatic Epilepsy) my guess is that the OP and her family know just as much as the doctors do at this point.

So I can understand the irritation with the nurse if she is challenging the doctor on the diagnosis.

 

[Pea-n-Me]

I respect what you're saying. ^ But "challenging" is the wrong word, here, I believe.

It's not an adversarial relationship - everyone's best interest is the child's well being.

If there - heaven forbid - was a medical incident, the nurse would have to justify her actions or inactions. She has duties inherent in her position. That is all we're saying.

We recognize these situations have a lot of emotion involved.

 

[DisneyOma]

Thanks everyone. I have written a text to my daughter asking her if she signed something. My daughter doesn't mind sharing info since it's in her son's interest but what does bother her is not knowing they are contacting the doctor. She has been through all sorts of things with doctors and has finally found one that she has a great relationship with. She doesn't want the school running to the doctor for minor info that she, herself, can provide. She wants him there for her in an emergency and not tired of always having to deal with the them for little things. This is the first doctor that will call her back ASAP. This is the first doctor willing to dig deeper. He has a severe non controlled seizure disorder called Doose.

Thanks everyone. This wasn't the case of questions about care she might administer. It was about asking the doctor to reword his document about his diagnosis. She actually asked him to change it. HER version of was full of mistakes and he didn't allow it. His case is severe and rare. She can't ask a doctor to change it because it's not what she is familiar with. He has several types of seizures not one. He has failed 18 meds.


Fortunately most nurses are professional. This particular nurse will talk to parents about other children not their own. Believe me, there is a lot of dirt on this nurse that I do not care to go into on a public forum. Her contact with this doctor had nothing to do about care. She, also, recommended a med. She isn't a doctor specialized in Epilepsy and she sure as heck shouldn't be recommending medication.



I wondered if it fell under FERPA. Thanks

Thanks to all for your insight.

As stated above, it has nothing to do about care. She wanted him to change his diagnosis. A school nurse should never, ever ask a doctor to change a diagnosis that a child has had for eight years.

Thanks for the explanation of posting at the same time. That definitely happens a lot. LOL

Asking to reword his diagnosis is wrong no matter what. It has remained the same for 8 years. He remains the same for 8 years. I think that is why I am questioning whether or not she had the right to contact him. It had nothing to do with care, period.

I 100% understand your situation in a partial care program. You are having a hand in their care. I would only hope a nurse would step in and articulate her concerns. And again, you are right. It isn't the same as what is happening with us. She definitely over stepped her boundaries suggesting a different diagnosis. For goodness sake, Epilepsy is difficult even for the well seasoned doctors. No case is the same as another. What I admire from all of his doctors is that they admit that the parents probably know more about the condition than the doctor.

So, you deal with this nurse on a first person basis, or is this all coming from your daughter?

 

[roseaster]

Exactly. We have a situation where the OP heard from her daughter, who heard from whomever at the Dr's office. This is information possibly passed on through 3-4 people.

The conversation could have ranged from, "You are dead wrong, Child has This syndrome, not That and he is on the wrong medication," to "I've noticed X in Child, have you considered That Sydrome, I had another similar student who had That syndrome and he did well on Z drug,"

I, too, get the emotional involvement, and it's hard sometimes to find a diagnosis and the appropriate treatment. Again, the bottom line is, legally, there is no HIPAA violation or any other violation. There is nothing actionable in what the nurse did.

Even if she did actually, "challenge" the diagnosis, she is still within her rights or scope of practice to do so.

She can't diagnose the child, but she is allowed to question a given diagnosis.

 

[aejammers]

I respect what you're saying. ^ But "challenging" is the wrong word, here, I believe.

It's not an adversarial relationship - everyone's best interest is the child's well being.

If there - heaven forbid - was a medical incident, the nurse would have to justify her actions or inactions. She has duties inherent in her position. That is all we're saying.

We recognize these situations have a lot of emotion involved.

Not to be argumentative with you, because I do respect your expertise as a nurse, but the OP said the nurse wanted "to change his diagnosis" and "reword his diagnosis" and "suggest a different diagnosis." That is challenging to me.

 

[aejammers]

Exactly. We have a situation where the OP heard from her daughter, who heard from whomever at the Dr's office. This is information possibly passed on through 3-4 people.

The conversation could have ranged from, "You are dead wrong, Child has This syndrome, not That and he is on the wrong medication," to "I've noticed X in Child, have you considered That Sydrome, I had another similar student who had That syndrome and he did well on Z drug,"

I, too, get the emotional involvement, and it's hard sometimes to find a diagnosis and the appropriate treatment. Again, the bottom line is, legally, there is no HIPAA violation or any other violation. There is nothing actionable in what the nurse did.

Even if she did actually, "challenge" the diagnosis, she is still within her rights or scope of practice to do so.

She can't diagnose the child, but she is allowed to question a given diagnosis.

I find it really hard to believe that if you had a child who had a rare syndrome that was diagnosed 8 years ago, who has been seen by several neurologists (who are experts in epilepsy), who have confirmed that this child does indeed have this rare syndrome, you would be happy to have a school nurse challenge your child's doctor. Really?

And I understand this is not a HIPAA violation. But I think she overstepped.

 

[roseaster]

I find it really hard to believe that if you had a child who had a rare syndrome that was diagnosed 8 years ago, who has been seen by several neurologists (who are experts in epilepsy), who have confirmed that this child does indeed have this rare syndrome, you would be happy to have a school nurse challenge your child's doctor. Really?

And I understand this is not a HIPAA violation. But I think she overstepped.

Honestly, no. Anyone can question anything they want, it doesn't make it true, and it doesn't mean that the doctor has to change anything that he/she wrote or diagnosed, as long as the nurse treated my child according to the agreed upon treatment plan his/her personal opinion really wouldn't matter to me.

Again, being on the other side, I know that these discussions occur all the time, and that health care providers often discuss and disagree about diagnosis.

My point was, and you are overlooking, is that this is 3rd or 4th hand information. No one was there for the actual call to the doctor so we don't know what the actual discussion was. All we know is how it was interpreted by someone who passed it on to someone, who passed it on to someone, who passed it on to someone, who reported it here on a discussion board.

What may have been interpreted as challenging by one person may be interpreted as clarifying by another. We don't know.

The point is, whether anyone likes it or not, it's not a violation, it's not actionable.

In the long run what does it matter if she did challenge it? It changed nothing.

 

[Maryr1]

I have a child with an IEP ere in New York State. I am also a nurse. If the nurse was calling the doctor to clarify and order-say a medication or a limitation (excuse from gym etc.) that is one thing. No HIPPA issue at all. She would speak with him/her or the staff and then follow up with a written or faxed order for a signature which would be then kept on file. However, if the request is for something more sensitive, at least in my daughters situation-the doctors office would call me and I would have to go and sign a release allowing them to send records, discuss diagnosis, treatment etc.....for all and every specific entity involved-not just "the district".For example-they could release records and discuss with the school psychologist, the school social worker, the specific teacher, the IEP coordinator etc. Whomever I wrote down. Each person had to be identified. This was done at the doctors office and clearly stated who they were allowed to release info to. The district would have you sign a release form telling them who they can release info to-not who they can collect info from. When my daughter was in lower grades she was classified as OHI (other health impaired) as her diagnosis was not usually assigned to children under 6 or 7-it had to be assigned when you could reasonably asses reading comprehension. Schools are reluctant to let kids stay indefinitely as OHI so could that be playing into this?

 

[tvguy]

I think common sense says that a medical profession, the school nurse, who is providing medical care to a child, has every right to discuss orders with another medical professional, the Doctor. Actually, it would be irresponsible if the nurse didn't if there was an issue.

Now around here, where school nurses were eliminated years ago, and administrators are left to deal with medical conditions, it would be different. As a non-medical professional, they WOULD have to deal only with the parent.

 

[acebatonfan]

The nurse would be carrying out the doctor's orders under the doctor's supervision and should be contacting the doctor for clarification whenever necessary, shouldn't she?

I was thinking the same thing. One of the big thing my pharmacology class emphasizes (I am a nursing student) is that nurses are held liable for any medication they administer, regardless of if it was the doctor who could be at fault (nurses have the right to refuse to administer a medication). If for instance, a doctor prescribes a medication dose that is way too much for the situation (like prescribing 100 units of insulin for a meal instead of 10 units), the nurse fails to clarify the dose with the prescriber, and gives the medication (and the patient has a serious adverse effect), the nurse would risk having his/her license revoked. If there's any questions, concerns, or misunderstandings, it's the nurse's responsibility to clarify them before implementing any care.

OP, I don't think it would be a HIPAA violation if it's between two medical professionals within the child's care team (I would classify the school nurse as a part of the care team, especially when the child spends a ton of his time at school).