"Nurses do doctor's dictations all the time"

[mzjones6]

I'm exactly sure what I should do about this situation. I wanted to hear from other nurses who've worked in the small office setting before and get some feedback on if I'm wrong, or if I"m just not understanding the way the doctor's office is run.

I've been working for this otoneurologist for about 3 months now. This is my first office job as a nurse, and it's a small office, with two doctors, myself, an LPN, two receptionists and a medical secretary. A couple of weeks ago the doctor asked me to help him catch up on his dictations because he's like 3 weeks behind. He wants me to dictate the appointments for his new patients because we have new patients 4 days a week through February. Well he sat down with me for 20 minutes one afternoon, and I watched him do one dictation, and now he expects me to be up to his level of dictating and I know that's not going to happen. He wants me to have it down to a science after one 20 minute session with him and I told him that was impossible because I have no idea on how to do dictation. The other doctor even said it took him years to have dictation down really well, so it shouldn't be expected of me to do it the way he does it after 2 weeks.

He swears up and down that RNs do dictation all the time for doctors, but I had never heard of it before now. I checked with my state board and they say its fine, as long as I receive the proper training, but if I'm not comfortable I shouldn't do it. The other side of this story is I asked if I could finally have my benefits, and he told me that if I don't do his dictations, I won't get my benefits, which I thought was a little unfair and illegal. He thinks I don't have enough to do in my role as his phone triage nurse so I need to be put on part time, but if I do the dictations, he'll keep me on full time and I get my benefits. I already do phone triage, all disability and SSA paperwork, PAs, and help out with scheduling and other office duties when I have the time, but he wants me to make the dictations my priority.

So I would like to know if this sounds on the up and up with any of you. I'm already uncomfortable in the office because the doctor has no real social skills, is very awkward, and the epitome of passive-aggressive. He's great with his patients, but has a hard time speaking to us as employees, and has every done through emails and the office manager.

Any thoughts, comments, and observations would be appreciated. Thanks.

[Ayvah, RN]

I have seen copies of office visit notes which say at the end "dictated by xyz", so I know docs do ask staff to dictate at times. Not a common practice though. Unfortunately I don't know much else of what is involved in it - sorry! Would be interested to hear others' thoughts though!

[nursel56]

I worked in MD office/outpatient clinic jobs for years and I don't recall ever seeing nurses dictate for a doctor. Most of the jobs were in teaching hospitals though, so that might be why they did their own. They also had people who's job it was to hound the residents who got behind. :) Out of curiosity, what are you dictating from?

[traumaRUs, MSN, APRN]

Hmm - I'm an APN and I dictate for myself, not my doctors.

Think you're asking for trouble.

And the doc sounds pretty rude too.

[PetiteOpRN]

As for the social skills, neurologists are neurologists.

But as far as dictation goes, the RN is technically scribing the note, and it is very, very common where I work. Every surgeon I work with, from trauma to ortho, has nurse clinicians that scribe/dictate notes. The MD edits and signs off on them. The plastic surgeon I work for has the nurses scribe every single note (he sees up to 60 patients a day in clinic). I think it helps me to be a better and more thorough nurse when I'm doing my assessment.

My tip would be to have him make you a binder with all sorts of different notes, so you can get used to what his typical exam is and how it is dictated, how he dictates abnormal findings, and what phrases he really like to use. (One orthopod likes to dictate, "the patient was seen today in clinic for final follow up and noted a full and gratifying resolution of preoperative symptoms...")

Learning to dictate is an important and marketable skill for an RN.

[traumaRUs, MSN, APRN]

Never having worked in an outpt environment as an RN, are you dictating from written notes, the doc saying things are okay, or what?

I've never heard this done and I know in my large 15 MD practice that the MDs and the mid-levels all do their own dictations. I wouldn't dream of asking one of the RNs to do my dictation. Not when my name is on it - nope.

[nursel56]

Having a nurse scribe wasn't done where I worked --- but as I said these docs were doing their residencies so perks like that didn't happen. In practice I can see how it would be a time saver. Almost every one of the residents were woefully behind on their dictation, but it is a skill they need to know even if they plan to delegate it later.

[PetiteOpRN]

Never having worked in an outpt environment as an RN, are you dictating from written notes, the doc saying things are okay, or what?

I've never heard this done and I know in my large 15 MD practice that the MDs and the mid-levels all do their own dictations. I wouldn't dream of asking one of the RNs to do my dictation. Not when my name is on it - nope.

Here's how I do it:

(new patient) I bring the patient to the room and do the general assessment and health history. Then I do a history of the present problem. Finally, I do a physical exam of the physical problem. I write everything down on my notebook (mini-legal pad). Then I go and stand in line to give report. When the MD is ready, I try and give a summarize version of the patient ("Mr. Patient is a 55 year old male with type 1 diabetes and no other health issues. 13 days ago he was welding and a piece of smelt became airborne, made contact with his right hand at the thenar eminence through his glove, and he sustained a burn. It was treated immediately with cool water and covered. No other treatment was sought. Today, a 1cm x 1.5 cm area of necrosis is noted at the injury site, surrounded by erythema and induration. There is no sensation in the radial thumb distal to the injury. range of motion is intact.")

We go back to see the patient together. MD says, "Petite has been telling me all about you. She said...." The patient agrees with the statement, or ellaborates (which I add to my notebook). At this point I start writing down every word that comes out of the MD's mouth. MD says, "the problem is..." that is my diagnosis. "You have a couple of options" is scribed as "we discussed several treatment options including..."

I hope that clears things up. The RN is present for the entire visit, so she is capable of documenting what happened. The MD ALWAYS looks over and edits the notes, so if something is incorrect, he can take care of it.

[traumaRUs, MSN, APRN]

Got it - thanks so much. That makes sense.

However, why not just hire a couple of mid-levels, then the RNs could do their job, the docs and mid-levels could see/dictate the notes themselves?

[PetiteOpRN]

I think part of it's a regional thing. All of the surgeons around here have at least one nurse clinician that scribes for them. Mid-levels are very few and far between, and mostly seen in GPs offices, not in specialty clinics. The surgeon did 6-7 years of residency AND 2-3 years of fellowships, physician extenders just do not have the training to treat patients independently in this setting, so they are a waste of money.

We have talked about developing a fellowship program, and in that case, the fellow would basically act like a mid-level. But it would be unfair to the NP/PA and the patient to expect the NP/PA to diagnose/treat within the sub-specialty.

As for the RNs doing their job -- they are! Our jobs in these clinics might be different than other clinics, but this is a big part of our job, and I take pride in doing it well.

The plastic surgeon I mentioned who sees about 60 patients in clinic on a given day is the only one in his sub-specialty in a 100-mile radius. He simply cannot waste time dictating, but his clinic notes are always ready to be faxed within 24 hours of seeing the patient because he developed a system that works for him.

[traumaRUs, MSN, APRN]

I do see your point and don't doubt that you are doing an accurate job at all.

[scfaysal]

i have attempted to post this somewhere else....i would like to scribe/dictate for a MD i work with but do not know if it is legal in Texas according to medicare/medicaid.

PLEASE HELP