Originally posted by btrfly76
We have been instucted by this surgeon not to call his office at all for any reasons including verification of orders. He also has the same non-dated H&P for every case-- the only difference is whether the cervical or lumbar spine is being worked on. How many patients actually have a temp of 98.6, a pulse of 60 and a resp. rate of 16 everytime? Everyone of his H&P has those values. I firmly believe that he has very good quality copy machine. We are expected to date the H&P for the day of surgery and pick the antibiotic ( Ancef 1 G IV, if no allergy to PCN;otherwise Vanco 1 G IV) and give Solucortef 100 mg IV also pre-op. Am concerned about
You need to bring this up to your manager. Many red flags here --which all add to up one point -- medical fraud, potential medical malpractice.
1. Who has this surgeon specifically instructed not to call his office at "all for any reasons including vertification of orders?" Is this in writing? Has anyone written this down as an order? What was done with this information? Did any nurse report this surgeon -- go up the chain-of-command? If no, why not? If the orders were not complete/verified -- what have the nurses been doing? Any incident reports filed?
2. H&P's need to be signed & dated -- in most facilities they need to be within 30 days of surgery. Don't some of the patients need EKGs? They all have the same vital signs -- has this issue been referred up the chain-of-command? It is illegal for you to date the H&P.
3. Have nurses been ordering the antibiotics? If so, this is not within nursing's scope of practice. Whose name is on the orders? Could also constitute fraud. Additionally, what if the patient had a serious reaction to the antibiotic -- whether through an undocumented allergy, etc. (On the H&P -- what is written down for allergies, specific past medical histories, etc.?)
This needs to be referred up the chain of command -- no matter how long this surgeon has been practicing. From what you've disclosed, fraud is involved -- this is very serious. Do not let yourself be intimidated by this surgeon -- document -- go up the chain of command. And do not go beyond your scope of practice for any doctor. If you need clarification of orders -- then call the doctor. Document the time you left a message & with whom. Leave a paper trail. Only document what you have seen, measured -- keep it objective. And fill out incident reports as necessary. Patient safety is #1.