If there's a form...do I have to use ALL of it?

  1. 0
    I'm working in a hospital and we have a 2-page form we use for our initial consult with a new patient. We have been using the form and then dictating the consult based on our findings/recommendations. We still have paper charts (!) so the form in part of the patient's record.

    Some of the physicians have decided they don't like our commenting on certain aspects of care which are included on our form. We've been instructed to just not comment on those particular parts of the form.

    My question, then...if it's on the form and the form is part of the patient's record, am I negligent for not commenting on those parts of the form? In other words, if there is a question about the patient's use of daily ASA or lipid management and I just leave it blank and then do not comment on it in my dictated consult, is that a legal problem?

    I've been told that the form cannot be changed, that it took months to get through committees for approval and that I should just ignore certain parts of the form. I'd like to hear from some of you and get an idea of how big a stink I should raise about this, if any.
  2. 9 Comments so far...

  3. 2
    "See MD note."

    Fortunately everything is electronic at all the places I work. However, when I haven't commented on something (either because I didn't know the plan or just didn't know period) I put "see MD note" or "MD to address."

    Gets me off the hook and pleases the powers that be too.
    NRSKarenRN and GrnTea like this.
  4. 0
    Thanks, Trauma. That will work in many situations for me.

    How about this one...I do a foot exam on each patient (I see diabetics) and comment on the (sometimes horrendous) state of the feet. I am not allowed to request podiatry consult, though. I mention the condition of the feet in my exam note but can't actually do anything about my findings. So if a patient's nails are so long that they curve over the end of the toes, do I just put it in my note to cover myself even if I'm certain the MD isn't going to do anything about it?

    I have this fear that a patient is going to have his/her foot amputated 3 years from now and my exam note is going to clearly state that there was an ulcer or unkempt feet...but I'll be in jeopardy since I noted it but did nothing about it.
  5. 0
    The problem with not filling it out entirely is that if you didn't chart you you didn't do it/assess it according to the law. The questions on a form used for an initial nursing assessment are designed to be answered by nurses. The fact that the physicians don't like it is really neither hear nor there. It's your license and you a$$ on the line. I would tell them that leaving out answers isn't an option for you. Explain nicely to them that the questions need to be answered to the best of your ability, because that is part of your job. If they don't like it at that point, I would say too bad. I'm doing my job and if you don't like it take it up with nursing administration.
  6. 0
    I was taught in nursing school not to leave blank spaces. If you do so, you can be held accountable. If they give you a form to fill out, fill it out to the best of your ability. You can make certain that if you don't and the patient or family complains the MD didn't address it, it will be said that you didn't make the MD aware of it.
  7. 2
    Quote from mammac5
    Thanks, Trauma. That will work in many situations for me.

    How about this one...I do a foot exam on each patient (I see diabetics) and comment on the (sometimes horrendous) state of the feet. I am not allowed to request podiatry consult, though. I mention the condition of the feet in my exam note but can't actually do anything about my findings. So if a patient's nails are so long that they curve over the end of the toes, do I just put it in my note to cover myself even if I'm certain the MD isn't going to do anything about it?

    I have this fear that a patient is going to have his/her foot amputated 3 years from now and my exam note is going to clearly state that there was an ulcer or unkempt feet...but I'll be in jeopardy since I noted it but did nothing about it.
    As an APN, you cannot refer for treatment?

    And, your Physicians overlook this w/o treating?

    It sounds as if you, as the APN, need to have a meeting with your Medical Director about this.
    NRSKarenRN and GrnTea like this.
  8. 0
    Dixie, that was pretty much my thinking as well. I treat diabetic patients...so the form includes a place to indicate whether or not the patient is on daily ASA therapy, are their lipids managed, foot care, and kidney function. Some of the physicians have decided that, apparently, these issues are too complicated for us to deal with as NPP (non-physician providers) and they don't want us to address them now. Just manage the blood sugar. Period.

    I have a contract until the end of the year and if all they want me to do for the remaining time is adjust insulin dosages and write scripts for diabetic meds/supplies at discharge, so be it. But I don't like the idea that I'm supposed to ignore the overall care of the diabetic person (rather than look at the entire patient holistically) and that may mean leaving this job when the contract is up. Also, so be it. In the meantime, though, I want to document in such a way that I will not have legal problems in future.

    Not trying to stir up trouble today...but to avoid trouble down the road.
  9. 0
    Then, if that's the case (and, you choose to stay there under these conditions), writing what traumaRUs said, "MD notified and will address", is about your only recourse.

    I don't blame you for looking elsewhere for a job. Like now.
  10. 1
    One thing to realize about consults (if these are truly consults you are filling out) is that per CMS guidelines, whoever is the author of the consult bills for the consult. That means, if the NP did the consult, the E&M code will be billed under the NP's provider number. As you know, the detail (or lack of detail) in the consult will determine the E&M code and the amount of money billed to the consult. With that said, consults are similar to H&P's in format with the exception of making sure there should be a "reason for consultation" (similar to chief complaint in the H&P) and "referring provider" (which identifies the primary provider who requested the consult).

    What you leave blank in a checklist or pre-printed consult form just means the activity or the component of the examination was not done, either deferred or omitted by you, hence, you can not comment on any abnormal findings on your assessment and plan that you didn't find to be a concern to begin with.

    Consults are done by specialty services (i.e., Cardiology, Pulmonary, Nephrology, Urology, and so on) at the request of the primary service (i.e., IM, Peds, and so on). Typically, these specialty consultants are only concerned with the reason why the service is consulted and will focus their recommendations on the body-system being addressed. For example, though Cardiology will be consulted for a refractory arrhythmia by IM, their consult will contain a head to toe exam but will be more detailed in terms of the CV portion of the physical exam and will maybe not mention "ugly looking toes". Their recommendations on the assessment and plan portion will focus on treatment of the refractory arrhythmia not the toe problem.

    Where I work, we also have computerized charting. However, the consults come in different templates depending on what service is doing the consult. The template for the Critical Care consults we do are definitely detailed because we address all body systems in the ICU. Some services do not have a detailed template and only prompt the provider to answer problem-specific physical exam questions. That is OK because these other services do not recommend treatment that is outside their scope (i.e., Cards recommending a TURP - I know that is kinda extreme).

    Update: read your subsequent posts, you are right in making sure toes are checked as part of a consult for diabetes. I would be very concerned that you are being asked to omit this important portion of the exam and management.
    Last edit by juan de la cruz on Feb 1, '12
    NRSKarenRN likes this.
  11. 4
    As I've been thinking about this today (because it's my day off) I wonder if it would best to go ahead and document my findings for all systems examined and then add a line at the end of my dictation saying something like, "Thank you for the consult. I will continue to follow this patient's blood glucose throughtout hospital admission and defer to admitting physician for all other care."
    CCRNDiva, NRSKarenRN, GrnTea, and 1 other like this.


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