Court Opinion

ID: 9627202
Source: CourtListenerOpinion
Date Created: 2023-08-22 08:38:35.154658+00
Date Added: 2024-06-11T18:06:42.948881
License: Public Domain

WITTIG, Justice,
dissenting.
Because the majority opinion erroneously allows a nurse to make a “medical diagnosis” contrary to express Texas law, I respectfully dissent. Further, despite numerous objections well understood by the experienced, respected trial court on the diagnosis/treatment issue and the related hearsay issue, the majority opinion divines a waiver, where there was none. I concur with the majority on the remaining issues one through seven.
As the majority aptly observes, a nurse may be qualified to render certain opinions within his or her field. That is not the issue here. Specifically, the State sought to introduce the history taken from both the 11-year-old complainant and her mother. The attempted method to escape the clear application of the hearsay rule was that the history was taken for the purposes of examination and treatment. However, a nurse is prohibited by law from making a diagnosis and treating the child.
The registered nurse examined L.G. on April 12, 1997. She spoke with both the mother and child but the history from the child was also taken separately. The nurse’s conclusion/diagnosis, however, included “everything.” Nurse Garison admitted she could not make a diagnosis or treatment “as a medical doctor.” Nevertheless, Garison claims she made a diagnosis at the end of the examination. At one point the trial court correctly sustained the objection that Garison was not qualified to make a diagnosis1 yet Garison repeatedly asserted she could make a diagnosis. The trial court also correctly sustained the defense objection concerning the use of Ritalin. Garison claimed she could diagnosis sexually transmitted diseases (albeit at least she recognized this activity was under the direction of a physician). After examining children, she claimed to be able to make diagnoses.
Nurse Garison was allowed to present the hearsay testimony of both N.M. and her mother under the guise “that information that’s important to you in making your medical diagnosis.” To complicate matters, the State offered this hearsay from the mother and child as medical records exception to the hearsay rule. But the records were not offered, no predicate for business records was made, and the trial court erroneously overruled the objections on lack of qualification to give a medical diagnosis, an expert opinion under *185Rule 703, and hearsay. Thereafter, the nurse testified about vomiting, withdrawal at school, irritability, aggressiveness, anger, screaming, identity of the accused, the alleged fondling, a genital examination, “disassociation” and articles from the American Pediatrics Journal, arrhythmia to the vestibule, and finally her diagnosis. “The examination was consistent with the history” (i.e ., all the problems related to the allegations of the mother and the child). In short, Garison testified largely as a physician in direct violation of the Medical Practice Act. Tex. Occ.Code Ann. § 155.001 (Vernon Pamph.2001).
Nurse Garison saw the child as the result of a law enforcement referral, an agency of the State. There is neither any evidence Garison saw the child for treatment nor that there was a treatment plan. Besides bolstering the testimony of the complainant, the apparent use of this nurse’s testimony was simple as a conduit for hearsay.
On cross-examination, defense counsel challenged: ‘You didn’t really make any diagnosis of all of this, did you?” She responded: “I came up with a diagnosis and treatment. The diagnosis was consistent with her history.”
The Black Letter Law
“A person may not practice medicine in this state unless the person holds a license issued under this subtitle.” Tex. Occ.Code Ann. § 155.001. Clear enough, you need a license to practice medicine. But what constitutes the practice of medicine? “ ‘Practicing medicine’ means the diagnosis, treatment, or offer to treat...mental or physical disease or disorder or a physical deformity or injury by any system or method, or attempt to effect cures of those conditions_” Id. at 151.002.
But you say, what about a nurse or a registered nurse? What can he or she do?
“ ‘Professional nursing’ means the performance for compensation of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or prescription of therapeutic or corrective measures.” Id. at 301.002(2) (emphasis added).
Quickly I add, a nurse may observe, assess, evaluate, rehabilitate, care and counsel the ill injured or infirm. Id. at 301.002(2)(A). So, too, as I described above, the nurse may perform certain acts delegated by a physician. Id. at 301.002(2)(G). Clearly, we can see a nurse is an expert in certain areas, as well-noted by the majority. Equally clear, I would certainly hope, that ordinarily a nurse is prohibited by law from unilaterally making a diagnosis or prescribing treatment. Ordinarily, diagnosis and treatment are the exclusive realm of the physician.
Exceptions
The law allows a nurse to testify to certain hearsay under limited circumstances. Some of these circumstances include: (1) child outcry under article 38.072 of the Code of Criminal Procedure; see also Villalon v. State, 791 S.W.2d 130, 135 (Tex.Crim.App.1990); (2) recitation from a medical record already in evidence, Johnston v. State, 959 S.W.2d 230, 237 (Tex.App.—Dallas 1997, no pet.); Castaneda v. State, 28 S.W.3d 685, 693 (Tex.App.—Corpus Christi 2000, no pet. h.) (including both testimony she collected rape kit and she read part of report by physician); (3) under the supervision of a physician or as a therapist (also under appropriate supervision),*1862 Gohring v. State, 967 S.W.2d 459, 460 (Tex.App.—Beaumont 1998, no pet.); and (4) certified sexual assault nurse examiners would presumably be given greater latitude in their testimony given their statutory authority for forensic examinations, care of sexual assault survivors, and statutory expert designation. Tex. Gov’t Code Ann. § 420.003; SANE Regulations, § 62.25, Office of Attorney General. Gari-son is not shown to be a certified sexual assault nurse examiner although she was in pursuit of the “SANE” certification.
Application
In our case, the State did not prove up any business or medical records exception. Tex.R. Evid. 803(6). The State did not prove the outcry exception. The State did not show Garison took the history under the supervision of a physician. The State was prohibited by law from obtaining a medical diagnosis or statement of treatment from a non-physician. Garison was prohibited by law from making a diagnosis or treatment of complaint. Ergo, the trial court erred in admitting the history for the purposes of diagnosis, by allowing hearsay from a physician journal,3 which necessarily could not be relied on by a nurse to make a prohibited diagnosis, and by allowing Garison’s testimony as to her diagnosis.
I see no reason to indulge in the futility of a harm analysis. Clearly a substantial right of the accused was abused by the wholesale admission of damaging hearsay. Tex.R. Evid. 103.

. The trial court appropriately sustained numerous objections by the defense and was well attuned to the defense's points that: 1) Garison was not medically qualified to make a diagnosis; 2) accordingly any testimony from the child or mother was hearsay; and 3), the basis of a diagnosis from medical literature was inappropriate and inadmissible because neither that information nor the hearsay could be the basis for telling the jury of the so-called "diagnosis.”

. Section 301.002(2) of the Occupations Code prohibits a nurse, explicitly, from making a medical diagnosis and prescribing treatments. R.N.’s may, however, make a limited “nursing diagnosis See Texas Nurses Ass'n, Ann. Guide to the Texas NPA, 6 (4th ed.1999). Contrary to the majority opinion, a nursing diagnosis is a term of art used in the nursing/medical profession. My research indicates that a nursing diagnosis is limited to attending to patient comfort, administration of fluids, or drugs per physician direction, and attending to the general welfare of a patient. A nursing diagnosis specifically does not include or allow a medical diagnosis, which was the question asked by the government.

. With a proper predicate, the learned treatise or journal could be properly admitted under Tex.R. Evid. 803(18), but not as a basis for a medical diagnosis.