Ever Admit without all the needed info?

We frequently admit without a written H and P or progress notes, as long as we have a physician's order and they appear eligible. Most of our records are received after the fact. If the patient is questionable on the referral visit, we will request records and go back to admit after the records have been received and reviewed (if eligible.)

Well, this is often a judgement call. There are times that we admit with very little paper evidence and going very much on the level of distress of the family that this patient is sinking fast. We keep trying to get info to back it up, but this can be very difficult if that patient has been one of those that had no established relationship with a physician and has refused diagnostic testing.

The other thing is that all those guidelines they give us to follow are pretty ineffective tools when used by themselves. They don't reflect the influence of co-morbidities upon the primary dx very well. I have seen so many articles showing that a lot of people who die don't meet the guidelines until their death is very imminent, and others who do last far beyond the 6 mo. mark.

Under circumstances where you are lacking in good third party medical information, but have a gut feel that this is the right thing to do, document everything you can about recent changes that caregivers and current physician see that is alarming them. Document a thorough baseline and if after a month or two you don't get any more information to back up the terminal dx and the physical changes just aren't happening, then discharge.

Thanks for the advise. I would love to have the pts records with the referral. I appreciate the help. Doing the eval and then getting the records seems so much more logical when it is at all questionable. You gals are great!!!!