MD Falsifying Charting

[annie.rn]

Last night was not the first time I have seen a doctor walk into a patient's room, never touch them and then chart a complete assessment. It happened again last night. I know this with absolute certainty. The pt. arrived from the ER w/ her husband, both in their early 60's and completely alert and oriented and with the program. They asked when they would see the admitting doctor. I asked if they had seen him in the ER to which they replied "no" and that they had not yet seen a doctor, just a PA. MD comes in about 30 mins. later while I was in the room. Stays for about 3 mins., asking her if she has any health problems or takes any meds to which she responds "no". He very briefly explains the plan of care and never lays a finger on her. I was in the patients room for another 30 mins. He never returned. I confirmed this w/ the pt. to make sure I am not lobbing false accusations. The MD then proceeded to write a full head to toe assessment on the pt. (S1, S2, reflexes, pupil reactivity, the whole 9 yards...had he done it, it would have been a 10 min. exam) He also timed it as if he had seen her in the ER, an hour before her arrival to our unit. It makes me really mad. It's fraud. Have you experienced this and if so, what have you done? I would like to report this to my supervisor. If it were ever investigated the patient is sharp enough to report that she was not physically examined by this MD.

[Rose_Queen, BSN, MSN, RN]

In many of our consults, the original note and assessment are completed by the PA. This is then cosigned by the physician with his/her plan of care added. It shows as "original note by (insert name of PA here); addendum by (insert name of physician here). Are you sure this isn't happening here?

[Emergent, RN]

It happens a lot.

I work in ER and see the doctors chart on many systems that I don't see them do a comprehensive assessment on. They are like us, under pressure to see more patients than practical, with mandatory charting requirements. Also, they they rely on things like chest x-rays, CT scans, labs, etc, to make their diagnoses.

[VANurse2010]

He was probably cosigning the PA's physical assessment. That is completely allowed to my knowledge.

[caliotter3]

I observed this more than once in LTC facilities. They liked to come in early in the morning, before night shift left, and on their way to their regular workplaces. I would return to the nurses station and find a stack of charts strewn all over the desk and noted they had a signed entry indicating that they had examined the residents. When I first brought this up to supervisory personnel (I was a new nurse), I never got an answer, much less a satisfactory answer.

On the other hand, there was a physician who was an RN in a previous life. She came in at a certain time of day (in the afternoon) and made complete rounds with the senior nurse. She followed up with everything and made efforts to do for her assigned residents what a doctor is supposed to do for their patients. I have always admired this doctor, and was never surprised when I found out she used to be an RN.

[annie.rn]

Maybe a PA is affiliated w/ him and had done the assessment. However, as far as I know, the hospitalists' group at the hospital I work for does not use any PA's. (Small community hospital so pretty easy to keep up with the provider staff and their structure) I know the pt. said she saw a PA in the ER but that was the ER provider. The doctor I am speaking of is the admitting physician. I have always been under the assumption that those are two separate entities. The ER provider does his/her assessment and orders and then does a consult to the hospitalist for admission. The admission physician then starts their own assessment. This MD's assessment was part of the admitting H&P.

Thank you guys for your suggestions. I will investigate this further.

[Esme12, ASN, BSN, RN]

I think this happens more that I'd like to admit. Before you report it...choose your battles wisely.

I was recently hospitalized and called the hospitalist on it....he was embarrassed to say the least. I hope at least the next few patients he didn't copy the previous assessment.

[tyvin, BSN, RN]

This is bad common practice as the docs read the previous note (PA or doc) and if it reads generic than why bother...I've seen more than one nurse do this as well. Why didn't you ask him while he was leaving the room or later... Did you do a head to toe assessment on the patient (of course you did). Are you sure he didn't see the patient prior...I see trouble here. You should have reported this to your shift supervisor if you were going to pursue it.

I can just see it. question to you: "Why didn't you report this when it happened?", You: "I had to write the gang on Allnurses site to get advice on how to proceed"...

So, you are going to pursue; my advice is have a talk with the doc but if you didn't report it right away and nothing happened to the patient, it's a little too late IMO. Pick the battles wisely; this does not sound like a wise battle unless you see this same doc repeatedly chart vitals they didn't take. Has to be a history, repeated offender type thing. If the doc did this one time (which of course that's what will be said if even that) than drop it. There are bigger fish to fry instead of a doc who did a lousy assessment.

There could be a number of things the doc could say to excuse his behavior. Was it his PA? Did you look at his charting extensively? Did you stare at the doc continually while he was in the room? What were you doing the whole time the doc was in the room? Did you question the patient because you resent the dr due to a previous incident? Careful... Also, I hope you haven't been going around talking about this; if it gets back to the doc he could feel his reputation has been tarnished, etc..., etc... get the picture.

The political scene in hospitals is poisonous and you need to learn how to navigate that aspect of what we call a career. I think you must be a new nurse; no? I know it doesn't sound fair but that's exactly what it is.

[KelRN215, BSN, RN]

Working in the hospital, I never once saw a Neurosurgeon carry a stethoscope. But, without fail, their progress notes always said things like "LSC, HRR" under their assessment. The residents also tended to write "VSS Afebrile" on everyone, even a child who'd spiked to 39 overnight and had had labs drawn because of it- because they just copied and pasted their notes from the day before. My favorite is when all week they'd be preparing to bring the patient back to the OR and would write "Plan, OR Thursday 11/20" and then on Friday after the child had already gone back to the OR, the plan would still be "OR, Thursday 11/20".

I would bet if I looked at some of my specialists' notes, there would be assessments documented that weren't done. My Endocrinologist is the only one of my specialists who actually does an assessment on me- the rest mostly just talk to me and some practice assistant does VS.

[VANurse2010]

I have two things to add here.

(1) I would tread very carefully OP, because I doubt very seriously you'll come out on the "winning" side of this if you pursue it. MDs have far more clout and protection than we could ever hope to have.

(2) While I don't condone false documentation, in a sense physical assessments are overrated. I've rarely if ever seen any major clinical decision made based on a physical assessment. It has largely been lost to the technology of imaging and labs.

[annie.rn]

The reason I didn't bring it up is because it was Thanksgiving night and no one was around on Friday morning. Plus, I DID want to get other's opinions here on AllNurses to see if it was worth it to proceed. I see the pitfalls now and will just let it drop. I'm not going to win this battle. I didn't talk about it w/ anyone else at work. I am 99.9% sure that the doctor did not examine the patient. No reason to get into the long winded particulars though.

I am not a new nurse. Very experienced, actually. (22 years) I am fairly new to this forum, however, and prior to finding it I've never had access to the opinions of thousands of my nursing peers all the while remaining anonymous. That is why I posted here first before taking any action. Seeing this behavior bothers me more now than it did when I was new. I see the doctors at the hospital where I work being so blase w/ the care of the patients and it seems as if a lot of them really don't give a crap at all. They have very little compassion and the patients have complications that could be avoided if things weren't blown off day after day. Again, something I could write pages about. I guess all my frustrations came to a head w/ this incident.

I understand that the world is not a perfect place and sometimes doctors (and nurses) look at a previous note to gather their assessment information. However, in this case, it was the initial H&P. The doctor had never seen or examined this patient before. I would think it should be a requirement that the MD gather tat least the first set of admission data with his/her own eyes, ears and hands. Sometimes, people haven't seen an MD in years and things can be caught that the patient isn't aware they even have. Let's say a heart murmur, for example.

I suppose I am too idealistic.

.

[Esme12, ASN, BSN, RN]

Medicine has become more and more about billable time and not what's the best for the patient. I have a chronic illness and I know that the specialists document a H/P with each new consult although I had a physician actually touch me for an exam in at least 3 years.....until I went to the ED at the end of October with abdominal pain and ended up in ICU.

Sad really.