Documentation of physician communication

Posted

Hello,

Have a question about documentation of physician calls and/or lack of response. I'm relatively new to home health and still in the learning phase. Majority of my experiences are in the hospital setting where physicians are relatively accessible unless after office hours. But if one is experiencing difficulties getting a response to a physician page, I have always follow my chain of command and informed the attending physician, unit Nurse Manager, house supervisor, etc.

I recently learned from a reply posted on this website that documentation or lack of action taken with regards to physician communications are one of the most common citation during survey.

I was wondering how this is handled in home care. What do you do about physicians that don't respond to pages, voicemail messages, etc. How is this documented?

Thanks,

caliotter3

38,333 Posts

I currently have this problem w/my client's doctor. My supervisor said to document date/time of calls, but she didn't say where. I decided to put it in daily documentation, gather a few instances and make a communication note to the agency. But more importantly, I am doing all non emergency doctor communications in writing, sent through the agency. I will take a stack of copies with me when I accompany the client on appts. The doctor can ignore my contacts all he wants, but with everything in writing, no one can say I am not doing my job.

nurse955

nurse955

53 Posts

caliotter3,

Your replies are always informational.

Thank you

Gommer

Gommer

Specializes in Home care, case management. Has 13 years experience. 8 Posts

It is my understanding this is one of the responsibilities of the medical director of your agency. If you need orders for a client and cannot get a response from the ordering physician, go through your chain of comand and aak if the med. Director wil sign orders temporarily. As an ADON I try, not always successfully to use these opportunities to educate doctors offices on state and Medicare regulations for home care. Another suggestion is faxing requests/ orders with a follow up call. Sometimes having hard copy gets results. I've even stopped in at offices and dropped off orders to be signed. Helps put new to faces and makes you a person instead of a voice on the phone.

caliotter3

38,333 Posts

With a previous agency I took to mailing stuff directly to the doctor and sending a 'copy' to the agency. I still never got any responses or any admonitions not to do what I had been doing. Almost all of my supervisors have always put the monkey clearly onto my back. They won't get involved at all, if they can help it. All they do is to criticize me because I can not create miracles. I am not buying a fax machine and phone to do faxing. My phone is a cell phone and will stay that way. I can not travel to the offices or even call most of the time, because I normally work at night. When I call the office, I have to take unpaid personal time to conduct the business. I have considered starting to bypass the office by mailing things directly to the doctor again, but I believe this agency will jump down my throat if I do that.

caliotter3

38,333 Posts

Never heard of my agency having a medical director.

twokidsmom,rn

twokidsmom,rn

198 Posts

I write verbal orders after I talk to MD. Then I have to fax it from the office. I do not get paid for this extra time and it can take alot of time to write orders, fax. One of the other nurses fax from home. I get in trouble if after a chart check from the office and I miss sending/receiving a verbal order but things get crazy when my census is over 20.

tabster224

tabster224

Specializes in Home health, Cardiac Tele, Doc's office. Has 24 years experience. 51 Posts

I thought every agency had to have a Medical Director.

twokidsmom,rn

twokidsmom,rn

198 Posts

We have a clinical nurse manager but not a medical director.

R*Star*RN

R*Star*RN, BSN, RN

Specializes in LTC, Med-Surg, IMCU/Tele, HH/CM. 225 Posts

We have a notes section. . . so we create a "physician contact note" documenting the date and time that the physician was notified and what they were notified of, if we left a message or spoke with the nurse or sent a fax. . .then there is this little box that you check for the case manager to follow up on, then the case manager (the RN) can write a follow up note such as "physician did not respond by such and such date" and so on.

HmarieD

HmarieD

280 Posts

I thought every agency had to have a Medical Director.

Medical Director is not required in all states.

indbletrble

indbletrble

32 Posts

In my agency there is an area on the visit note where the nurse can document communication with the MD.....(MD name, what the issue was, outcome of the conversation) for something found that visit. If the MD was not available at the time of this call or additional communication is necessary, then all subsequent communication is documented on a 'Narrative Note' to include date, time, conversation and outcome. All are a part of the patient's medical record.