X-Ray Requisition Chart
RNs in the Extended Class

RNs in the Extended Class

Introduction
As a result of recent changes in Ontario legislation, the College of Nurses of Ontario (CNO) has created a new, fourth class of registration for Registered Nurses (RNs) - the Extended Class (EC). The new Extended Class RN or RN(EC) is able to perform a range of diagnostic and treatment health care services including:

Communicating a diagnosis of common disorders and diseases
Ordering certain x-rays and ultrasounds
Ordering certain lab tests
Prescribing certain drugs

Members of the Extended Class - RN(EC)s - are authorized to order x-rays of the chest, ribs, arm, wrist, hand, leg, ankle, and foot, and to order a mammogram. They are also permitted to order diagnostic ultrasound of the abdomen, the pelvis and the breast.

MRTs should know about the new legislation and regulatory changes and what it means for their work with nurses with the Extended Class designation.

The New Act
The Expanded Nursing Services for Patients Act, 1997, which was proclaimed on February 11, 1998, greatly improves the opportunities for primary health care nurse practitioners to contribute to the quality of health care for people in Ontario.

The new legislation recognizes the important contribution primary health care nurse practitioners have been making and removes restrictions that limited their ability to diagnose and treat a range of common illnesses independently.

Primary health care nurse practitioners who wish to practise with the additional authorities detailed in this publication must obtain an Extended Class certificate. The RN(EC) has demonstrated to the CNO his or her competence in the areas of health assessment and diagnosis, therapeutics, role and responsibility, health promotion and disease prevention, family health, and community development and planning.

As well as the three controlled acts authorized to nursing in the Nursing Act (1991), RN(EC)s have the authority to perform three additional controlled acts: communicating a diagnosis of a disease or disorder, ordering diagnostic ultrasound, and prescribing a defined range of drugs. Changes to other Acts and regulations authorize RN(EC)s to order specific x-rays and laboratory tests.

Changes to the Healing Arts Radiation Protection Act
As medical radiation technologists, it is important to note the following changes to the Healing Arts Radiation Protection Act (HARP) which have been made to facilitate RN(EC)s in meeting the new mandate:

6 (2)

6 (3)

Standards of Practice for RN(EC)s Ordering X-rays and Ultrasounds
RN(EC)s will be expected to comply with standards that have been developed by CNO. The standards of practice published by CNO state that RN(EC)s may order specific x-rays and ultrasounds to:

Confirm the diagnosis of a short term, episodic illness or injury
Rule out a potential diagnosis that, if present, would result in consultation with an appropriate physician for treatment
Assess/monitor ongoing conditions of patients with stable chronic illnesses
Screen for diseases

Who is a Nurse Practioner?
Identifying which nurses are authorized to order the x-rays and ultrasounds described above is complicated by the fact that several groups within the nursing profession refer to themselves as "nurse practitioners".

This legislation, however, applies only to the RN who is a member of the Extended Class. The CNO has indicated that the Extended Class is currently available to RNs who have successfully demonstrated their competence as primary health care nurse practitioners. A primary health care nurse practitioner is a registered nurse with advanced knowledge and decision-making skills about health assessment, diagnosis and health care management, who works in a primary health care setting. She or he is usually community-based and provides a wide range of services that include women and children's health, health promotion, illness and accident prevention, treatment and cure of illnesses, rehabilitation and support services.

With the new legislation, primary health care nurse practitioners in Ontario can apply to the CNO for registration in the Extended Class and, if they successfully complete the CNO assessment process for registration in the Extended Class, will be able to provide the increased range of services independently and without a physician's signature.

How to Identify an RN(EC)
Currently, only primary health care nurse practitioners are eligible to apply to the CNO for registration in the Extended Class. And, only those who can add (EC) to their signature are allowed to diagnose, prescribe drugs and order certain x-rays, ultrasounds and lab tests.

Since the title "nurse practitioner" is not protected under the Nursing Act, it may be used by nurses who are not members of the Extended Class, so it is important to look for the RN(EC) on all requisitions for x-rays.

The CNO has indicated that acute care nurse practitioners (also referred to as clinical nurse specialist - nurse practitioner) and others sometimes referred to as nurse practitioners, are not eligible for registration in the Extended Class at present.

All RN(EC)s will be required to provide their name and professional designation - RN(EC) - on all documentation including x-ray, ultrasound or lab requisitions.

If you need information about whether an RN is a member of the Extended Class, you can phone the College of Nurses.

What MRTs must know
X-rays

RN(EC)s are authorized to order x-rays of the chest, ribs, arm (up to and including the head of the humerus), wrist, hand, leg (up to and including the head of the femur), ankle or foot, and mammograms
Shoulder and hip x-rays are not within the scope of practice of an RN(EC); however, it is recognized that an x-ray of the humerus or femur may include part of the shoulder or hip in order to visualize the proximal portion, as determined by the MRT performing the x-ray
RN(EC)s are not authorized to perform an x-ray - that is the responsibility of an MRT
RN(EC)s are not authorized to interpret an x-ray - that is the responsibility of the radiologist
RN(EC)s are accountable for knowing the contraindications to ionizing radiation exposure and the risks and benefits of ordering an x-ray

Ultrasound
The RN(EC) may order diagnostic ultrasound of the abdomen, pelvis -including obstetrical ultrasound - and breast, but he or she may not perform or interpret a diagnostic ultrasound.

Again, the RN(EC) is accountable for knowing the risks and benefits of ordering an ultrasound.

Procedures
The RN(EC) will complete the x-ray or ultrasound requisition and indicate:

The examination being ordered
Which views are requested
A description of the clinical reason for the examination

The RN(EC) will:

Sign requisitions with his or her name and the Extended Class identifier (EC)

The RN(EC) may:

Include his or her identification number issued by the Ministry of Health for OHIP payment purposes

The need for any other x-ray or ultrasound not included in the RN(EC) authority must be ordered by a physician, either by means of a medical directive or a specific order for the individual patient.

RNs who do not have an Extended Class registration may still complete an x-ray requisition under a medical directive developed in accordance with the joint policy of CMRTO, CNO and the College of Physicians and Surgeons of Ontario. The CMRTO and the CNO have developed a matrix comparing the two situations, which can be found in the section "X-Ray Requisition Chart".

Remember...
The RN(EC) in no way replaces the MRT who remains responsible for the operation of the x-ray machine.

The RN(EC) may request further explanation or clarification of the radiologist's interpretation for the purposes of a diagnosis.

It is the responsibility of the RN(EC) to know when and when not to order an x-ray that will expose a patient to the risks associated with an x-ray.

The RN(EC) will, on the basis of the interpretation offered by the radiologist, make decisions about the diagnosis and treatment of an illness or condition including the decision to consult with a physician as per the standards developed by the CNO.

Further information regarding the role of the primary health care nurse practitioner may be obtained from the CNO in their publication entitled A Primer on the Primary Health Care Nurse Practitioner.

(The CMRTO would like to acknowledge the CNO for its cooperation and contribution to the development of this publication.)

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