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Documentation Tips: Teaching Interns and Residents

Posted on Mon, Mar 27, 2017
Documentation Tips: Teaching Interns and Residents

Our recurring series of documentation tips for clinicians.

By Timothy Brundage, MD

A countersignature by itself is insufficient for both documentation and billing purposes.

Acceptable Documentation

According to CMS, at minimum, the following documentation must be included when billing for services provided by the intern/resident with a teaching physician:
 

  • "I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care."
  • "I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note."
  • "I saw and evaluated the patient. I reviewed the resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”

Unacceptable Documentation

Unacceptable documentation by a teaching physician includes the following examples with a countersignature:
 
  • “I saw and evaluated the patient”
  • “I reviewed the resident’s note and agree with the plan”
  • “Agree with the above...”
  • "Patient seen and evaluated...”
  • “Discussed with resident and agree with plan...”

Resources:
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Timothy Brundage, MD, CCDS, is a hospitalist at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his medical degree at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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Embrace Patient Surveys to Improve Care

Posted on Wed, Mar 22, 2017
Embrace Patient Surveys to Improve Care

By Ginger Wirth, RN

We live in a world where surveys surround us. You can’t go to a restaurant, big box store or even a gas station where there isn’t a survey attached to a visit. It has become a reality of the times.

Cashiers at retail stores circle the survey link on the bottom of the register receipts and directly ask us to take time to fill out the survey. And, don’t forget, if you register, you could win a $500 gift card!

Healthcare has been surveying its patients forever, and unbeknownst to the everyday consumer, it’s tied to reimbursement for hospitals and now providers. We rarely mention to patients that they are likely to get a survey on discharge. However, we should encourage everyone on the care team to tell patients and families that there is a survey, and that we will use any and all feedback that is shared to improve care. This feedback is truly a gift, even if it is negative or points out ways we have failed in our mission.

We also have an opportunity to educate our providers and the care team about what the surveys are asking. Do you know what questions are on the HCAHPS survey? Do you know the methodology for selecting who receives a survey? Which patients are given the ED survey? Who gets excluded? Which vendor your facility or organization uses to administer the survey? These are all important answers that should be provided to your care team. If you’re working in a hospital setting and can’t answer these questions, you need to do a bit of studying. Here’s a resource for more information.

There’s nothing to say we can’t make this an open book test. We should ensure that we know the questions on the survey so that we can help educate our patients and families. As healthcare providers, we only get “credit” for those top box results; that is to say the “Very Good” and “9/10” scores. Some providers may not even be aware of that simple fact.

Isn’t it important that we give credence to a survey related to the healthcare we are providing? Surveys and other mechanisms for providing feedback are a sign of our times. Let’s leverage that culture to make the care that we are delivering the best it possibly can be. Let’s use the survey to not only improve, but to showcase the great care we are providing.

Ginger Wirth, RN

Ginger Wirth, RN, joined EmCare in 2013 as a Divisional Director of Clinical Services for the Alliance Group. Her goal is to make positive changes in healthcare by helping others focus on quality, excellence, and the overall patient experience. Wirth regards her role as Director of Clinical Services as the ideal opportunity to partner with nursing, physician and facility leaders to make positive changes to the entire patient care experience. Her 20-plus year nursing career has been dedicated to quality and excellence, promoting overall positive outcomes and safety for patients.

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What Happens When Doctors “Just Listen” to Their Patients

Posted on Mon, Mar 20, 2017
What Happens When Doctors “Just Listen” to Their Patients

“Just listen to your patient; he is telling you the diagnosis.”

This medical maxim is attributed to Sir William Osler (1849–1919), widely considered to be one of the greatest physicians and diagnosticians of all time. Although Osler’s advice might seem impractical in today’s healthcare environment in which clinicians face increasing pressure to deliver care faster and more efficiently, a recent experiment by a New York City physician suggests that letting patients speak about their health problems without interruption can be both practical and beneficial for both parties.

Studies have shown that doctors interrupt or redirect patients within the first 30 seconds after they begin speaking, and two studies found the average time to interruption was 18 and 12 seconds, respectively. Danielle Ofri, MD, a physician at Bellevue Hospital and an associate professor of medicine at the New York University School of Medicine, confessed to having been guilty of such interruptions and redirections in her recent essay in STAT (adapted from her new book, “What Patients Say, What Doctors Hear”). Like many of her peers, she feared her patients would “ramble on ad infinitum” if she didn’t home in on their top priorities quickly. But after reading a study by a group of Swiss researchers who found that when doctors did not interrupt, the average duration of their patients’ monologues was a mere 92 seconds, Ofri decided to do some informal research in her own clinic the next day.

Throughout that day, she asked each patient how she could help her or him, then quietly clicked on a stopwatch to time their responses. She encouraged them to keep talking until they had finished telling her everything they wanted to discuss. Her first two patients, who were basically healthy individuals, spoke uninterrupted for just 37 seconds and 32 seconds, respectively. Her third patient, who had unresolved back pain plus glucose, cholesterol and weight that were creeping up, spoke for two minutes.

But Ofri was understandably worried about what would happen with her next patient, Ms. Garza (not her real name). Garza not only suffered from a wide range of chronic, insoluble pains compounded by anxiety, depression and irritable bowel syndrome, she also had to care for her demanding, elderly mother, who had insomnia and routinely was up and complaining at all hours during the night. “Exactly the type of patient who can drown you with a list of complaints,” Ofri noted. In addition, Garza, who had been a teacher in her native Argentina, had a penchant for offering observations about New York City’s “pretensions of culture” and its lack of sophistication compared to Buenos Aires.

Ofri feared that if she allowed Garza to say everything she wanted to without interruption, “the visit would unfurl like a Borges labyrinth. We’d tumble down a dizzying path of her symptoms that would encompass every organ system of her body, plus a list of her mother’s medical woes and a stinging critique of the Metropolitan Opera’s soulless production of ‘Turandot.’” Nonetheless, Ofri understood that if she excluded “difficult” patients from her experiment that day, her data—informal though it was—would be flawed. So, despite her qualms, she encouraged Garza to keep talking until she had “fully, truly, absolutely come to the end of all that she had to say” while Ofri jotted down the long list of issues. When Garza had finally talked her fill and Ofri clicked off the stopwatch without looking at it, she estimated that between eight and 10 minutes had passed. Later, when she checked the stopwatch, she discovered that even Garza’s lengthy monologue had actually taken just four minutes and seven seconds.

Garza had already had an extensive workup, and all the results were negative. Ofri explained to her that something was going on and that “Medicine is very poor at explaining pain syndromes, but that doesn’t mean we can’t go ahead and start treating your symptoms.” She and Garza spent the remainder of the time reviewing the list of issues. They went through each type of pain, which included shooting pains in Garza’s gums, a painfully sensitive scalp and neck pain that radiated down her spine, and identified treatments that might help, including ice packs, local heat and massage, physical therapy and pain medications. They discussed how antidepressants could be helpful, how seeing a therapist could decrease Garza’s stress, how she might get help in caring for her elderly mother and the critical role of exercise in treating chronic pain. Then they put together a written plan based on those discussions.

Even so, the visit didn’t run overtime by much. Before leaving, Garza said, “Just talking about all this has actually made me feel better.” To Ofri’s surprise, it had made her feel better, too. In fact, it was the first time she had ever felt good after a visit with a patient with chronic pain. “I was actually doing something to help, rather than just rearranging deck chairs,” she explained. “It’s a reminder that doctors sometimes need to zip it up and let the patient talk uninterrupted. Although it may feel like time is being wasted, it could actually make everything much more efficient.”

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