I recently went to a seminar where it was suggested that MD needs to document need for observation and assessment for ____________ (reason they were in hospital). I discussed this with our medical director and he does not feel that it is necassary, other than the certification, states that record from hospital should document their reason for skilled care. Anyone care to share their feelings regarding this ? do I continue to fight this, does it do any good for me to document it in a progress note? How do I handle this ?
For example the reasident I brought to him was hospitalized for urospesis, returned with PICC line and IV antibiotics, was not seen by her primary upon return becasue he was out of town for vacation. He does not like NP to see his residents, He did give verbals orders for resident upon admit. I was asking the Med director to document that this lady needed observation and assessing for diagnosis of urosepsis and risk for recurrent symptoms as well as risk for local infection at PICC site. He would not do it. instead said we needed to look at our certification process, which I am doing but was I wrong to ask this ?
Do anyone have any examples of completed certifications and what they should look like (what should be on them, all my facility has been putting is the reason they were in hospital should therapy be included ?
Thanks for all your help