Physicians Who Don't Do Assessments

Nurses Safety

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I am writing this somewhat heavy-hearted because what I felt needed to be done did not feel good, but needed to be said... If anyone can relate, I'd love to hear from you.

Recently, a patient I cared for passed away and I feel this death may have been preventable, or at least foreseen. An unfortunate series of events occurred with abnormals reported to the physician and a very non-aggressive approach was taken. This was the last straw for me and the action I've taken since is not a retaliatory effort.

I have noticed this physician write "notes" documenting the heart and lungs were auscultated in his patients, but while present in the room, I've never witnessed the stethoscope touch the patient. This is not the case with ALL the patients, just some. This doctor does not communicate much with nursing staff and disregards information others might find critical and gives no explanation so...I find myself referring to his notes to help piece together his idea of the presenting patient's clinical picture. After doing so, I've realized he has documented an assessment he did not do. I reported this.

As much as I think the physician is a nice guy and pleasant enough, that is no excuse for skimping on patient care. It's difficult to hear patients tell me "I just love Dr. So-and-So. He is just wonderful!" And while he can be, what he does from time to time, is not wonderful - it's dangerous. I can't shake what I know goes on on my side of the bed from my head.

Maybe it is a lie from the enemy to make me feel guilty about my decision to report this doctor. It's just unfortunate that while this greatly respected man goes about his business, I feel I have stabbed him in the back. However, I know, in reality, no one makes him practice the way he does. I almost wish I didn't know what I do so that it can stop eating at me.

Has anyone come across this issue or something similar? This is extremely sensitive and unethical and I realize, a very serious accusation. However, I can not ignore it.

:down: -- Torn

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Specializes in Trauma-Surgical, Case Management, Clinic.

Not sure what kind of facility you work in but I've worked at many diff hospitals and this seems to be the norm with the majority of docs I've encountered. Now with computer charting some docs will enter a note with an assessment and never even round on the pt. I've seen a few docs only chart what they actually assessed. For instance a focused assessment on a surgical pt. I see things all the time like docs ordering antibiotics and breathing treatments for resp probs and charting lungs CTA. Same thing for tele pts with all kinds of cardiac issues and docs chart that everything is normal. I feel for them bc it's a tough, stressful job and they have tons of pts while nurses only have a few. I just try to advocate for my pts, notify docs and document everything. I do know that our docs and everyone reads our nursing notes so I just try to leave a paper trail of any ongoing issues and what has been done. I don't know about reporting a dr for not doing assessments (your word against theirs), but next time you find yourself in a position when you feel like enough isn't being done, there is always someone above the doc to discuss your concerns with (i.e. medical director).

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Documenting assessments that were not done is considered fraud in my facility. I understand they are busy and I truly feel for them b/c Lord knows I fully understand the meaning of the word. I just don't think it's an excuse to not do your job properly...

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Specializes in Critical Care.

"Doorway rounds" are allowed per CMS rules and whether or not Docs can use other's assessments in their prog notes is up to facility policy, but often Docs can enter assessments into their prog notes as assessed by others, including Nurses. For instance, Docs typically include vital signs in their prog notes, even though I've never seen a Doc take vitals. By the same premise, they can enter "lungs clear bilaterally" based on a Nursing assessment.

H&P's are a little different however.

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Specializes in Trauma Surgical ICU.

Very true, many of the PCP in my facility rarely walk in the room unless there is an issue or family at the bedside to update. Many times they gather their information from the nursing staff and issues we brought to their attention. I would imagine the MD/PCP would never leave the hospital if they assessed all their pts.

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Specializes in Critical Care, Education.

Hmm - I realize that different clinical environments may have different rules, but physician services are directly reimbursed by CMS and other ins companies. Even a cursory search of CMS fraud cases will reveal that 'billing for services not provided' is a very common finding. How would this be different? Unless the physician includes "as per nurse's assessment" or some other indication that the physical findings were obtained from another source, the information is presumed to have been obtained first-hand via physical assessment.

They are getting PAID (a lot more than us) for fulfilling the role of attending physician. This means they have to actually examine and evaluate care, perform interventions, modify treatment plans, talk to the patient & family . . . NOT just whiz by and ask "howzitgoing?" The doc knows this. We know this. We can't pretend it away. The doc should not be able to 'nice' us into staying quiet when we know what is actually happening. That makes us complicit. I guarantee you that if anything 'bad' happens, the doc will throw you under the bus very quickly.... "naturally, I would have done XYZ if the nurse had only informed me"

Reflecting on my own experience, (critical care) it always seemed that the 'nicest' docs were the ones that tended to take shortcuts - they took advantage of their social capital -- "Can you do _____ for me just this once, I'm in such a rush and you are such a wonderful nurse" The cranky old wart hogs pay a great deal of attention to even the smallest detail and never take shortcuts - they grill you about everything and make you sit down with them and go over everything in the chart just to be ornery, right? .... but which one do you really trust?

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Specializes in ED, ICU, PSYCH, PP, CEN.

A couple of us were actually talking about this the other day. I was telling them that my oncologist puts her stethoscope up to my back but doesn't actually touch it. Wondering how she hears breath sounds from across the gap and through 2 shirts. I can't make fun of her though cause she cured my cancer.

LOL

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.

Actually doorway rounds are not allowed. When a provider writes any note (H&P or progress notes), the payment from CMS is based on the complexity of the evaluation and management (E&M) which includes the physical exam (which should have been done hands on the patient) and the assessment (diagnosis) and management (plan of care).

When a provider writes vital signs and physical exam findings of a nurse or another physician, their signature at the end of the note certifies that they agree with those findings and deem them accurate. If questioned later, the only reasonable explanation a provider can offer is that they checked the patient themselves and agree with the finding. That makes it dangerous for providers who never touch a patient yet write physical exam findings on a patient's chart.

However, I would never assume that a provider writes notes without touching a patient -- the process of arriving at a diagnosis takes much more than a cursory listen to lungs and chest. The process requires looking at labs and radiology films, etc and tying the entire clinical picture together.

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Interesting point.

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Specializes in Critical Care.
Actually doorway rounds are not allowed. When a provider writes any note (H&P or progress notes), the payment from CMS is based on the complexity of the evaluation and management (E&M) which includes the physical exam (which should have been done hands on the patient) and the assessment (diagnosis) and management (plan of care).

When a provider writes vital signs and physical exam findings of a nurse or another physician, their signature at the end of the note certifies that they agree with those findings and deem them accurate. If questioned later, the only reasonable explanation a provider can offer is that they checked the patient themselves and agree with the finding. That makes it dangerous for providers who never touch a patient yet write physical exam findings on a patient's chart.

However, I would never assume that a provider writes notes without touching a patient -- the process of arriving at a diagnosis takes much more than a cursory listen to lungs and chest. The process requires looking at labs and radiology films, etc and tying the entire clinical picture together.

CPT code 99231 for Hospital follow up rounding requires only a "problem focused physical exam" which can include only one organ system, and three vital signs is considered one organ system. "doorway rounds" isn't a technical term so there is no hard definition, but this CPT code is what is usually referred to as a "doorway rounds" in my experience, and can meet all the requirements with a patient assessment that only includes 3 vitals.

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.
CPT code 99231 for Hospital follow up rounding requires only a "problem focused physical exam" which can include only one organ system, and three vital signs is considered one organ system. "doorway rounds" isn't a technical term so there is no hard definition, but this CPT code is what is usually referred to as a "doorway rounds" in my experience, and can meet all the requirements with a patient assessment that only includes 3 vitals.

Huh? where did you get the information that three vital signs meets the one-organ system requirement in a focused physical exam? A focused or abbreviated physical exam is used when you're only addressing one organ system. For example, an OB-GYN is seeing a post-partum patient. The physician would only check the episiotmoy incision, feel the uterus, ask about breast tenderness, etc. The Neuro, CV, Pulm, etc are omitted.

Vital signs are not usually part of an organ-based physical exam...it can certainly be included in corresponding body systems (BP and HR in cardiac, RR and O2 sats in Pulm) but they are typically part of general or constitutional findings in the note.

I don't know where you're drawing your information from and calling it "doorway rounds". Are you a provider? I am a provider (a NP) and the facts you're quoting are bordering on fraud.

See: Focused History or Exam | UW Medicine, Seattle

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