office setting nurses

[littlekaneRN]

Hey everyone,

this is a question and a rant so I apologize in advanced but I truly feel stuck.

i am a nurse at a relatively small practice with 3 providers. Each doctor gets 2-3 nurses to help see their patients. Our responsibility is to assist in procedures and transcribe the visit documentation. Rarely we have a nurse on the phones, the nurse who is usually scheduled to do calls ends up having to see patients if we get behind.

I am curious how your office does calls? How are the divided up between nurses? Frequently, at the end of any given day there can be anywhere from 20-30 calls left to do after all of our patients have been seen at the end of the day, they vary in priority. I find it so frustrating to have to try to do all these calls at the end of the day and we generally stay an hour later than scheduled to do them. We have nurses that avoid doing calls or are extremely inefficient which does not help. I live an hour away from our office so leaving so late every day makes me really bitter about it.

I have tried talking to my manager about this but nothing ever changes. She did start assigning nurses to certain desks at the end of the day to have a nurse in front of the phone but that doesn't mean they pick them up to call anyone. I have been told we will not have a full time phone nurse.

what is your offices strategy on calls? Do you experience the same issues? Thanks so much for your time and input.

[klone, MSN, RN]

I'm the only nurse at our clinic, so I do all the phone triage.

Based on what you're describing, it sounds like you have 5-6 nurses? Are they all RNs, or are some LPNs? Is there any reason why you cannot rotate and each nurse is responsible for phone triage each day? And they must make sure that all calls before 4pm are cleared by the time they go home.

And why on earth does the practice need 2-3 nurses per provider? That seems like a tremendous waste of financial resources. Our practice gets one MA per provider, then there is one RN who does triage, does the daily office management, and takes their own patient load.

[klone, MSN, RN]

Also, what do these calls consist of? It seems like for a small practice, 30+ triage calls per day seems like an awful lot, so I'm wondering if you take care of ALL phone calls, even those that might be more appropriately handled by clerical staff (such as scheduling, etc)? Is there any way that all calls can go through a clerical gatekeeper, and only those calls that are clinical in nature are passed on to the triage line?

[littlekaneRN]

Thanks for the reply klone. Our office actually has 11 RNs!! We have probably 8-9 working together on any given day and it usually comes down to 3-5 of us responsible to finish the calls. It all depends on the leave time and experience of the nurses. Literally all calls are forwarded to the nurse, with the exception of only scheduling. We call our test result pts, refills, prior auths, follow up on any issues, questions, ect. Our front desk situation is tricky, we had a time where if a pt hadn't been seen in over a year and wanted a refill they needed a follow up. They weren't comfortable telling that to people, so nurses had to. It's so ridiculous sometimes and it's really stressful to try to finish it all in one night.

[klone, MSN, RN]

That's nuts. For three providers? Do the RNs see any of their own patients, or are they there strictly to help the providers? Does the clinic utilize any MAs?

[littlekaneRN]

The nurses all see patients with the providers. I only ever see my own when I do cosmetics(it's a derm office so some of us do peels or laser), which isn't all that often. Our docs see 6-7 pts/hr each. Nurses do it all, turn over rooms, take histories, assist. Our main function is to assist and transcribe the visit, so we are essentially writing the docs notes. The physician who owns the practice feels he gets a better quality employee with RNs which is why there are so many of us but we do have one MA, she does all the same tasks as the RNs except injection of local anesthetic.

[littlekaneRN]

Klone, how are things run in the clinic you work at??

[klone, MSN, RN]

As I mentioned, we have 1 MA per provider (3 providers). Our provider visits are 20 minutes long, three per hour (it's an OB/Gyn office). The MAs room, take vitals, assist with procedures, turn over the rooms, do UAs and send specimens to the lab.

As the RN, I have my own patient load (I only see 6-8 patients/day), plus I do all the triage (phone and in-person), I handle taking care of any abnormal labs, call in prescriptions to the pharmacy on behalf of the providers, and I handle the day-to-day operations of the clinic.

The providers do their own charting/encounter notes.

We certainly don't have the volume you do, but it would seem to me that your clinic would be able to function with one RN/MA team per provider, plus another RN who is dedicated solely to triage (phone calls) and labs/authorizations.

[littlekaneRN]

Wow I wish we'd try it out.

nurses with providers see that pt from start to finish, any thing that happens during that visit is our responsibility, handling specimens, getting then lab slips, sending rxs. When that's done we move on to the next one, take their history, write their visit note, send em to check out. By the time we're done with one patient, my doc is in with the next nurse and my 3rd nurse is probably waiting for the doc to come in her room. I am one of the only nurses who will call someone when waiting for the doctor to go in my pts room.

We do, most days, have 1 rn to do calls but they are the "float/desk" where if any provider gets behind they abandon ship at the desk to take back their patients. Usually you just get stuck seeing patients all day while the calls stack up. We asked to please have one nurse at the desk full time and it got a resounding "no" from the doc who owns the practice. For a doc who has so many employees you'd think he'd go for it.

No nurses are allowed to leave until all the nurses are done working. Ugh.

Anyway, thanks again for your replies, I was wondering for so long "how do other offices do this?"

[Cali2015]

I'm the only RN in the clinic and the APRN and I usually divide up the calls according to content. I screen any callers asking for an appointment and book them accordingly. Our APRN handles calls which require actual medical advice. I help her with procedures, handle all the specimens, draw blood, give all the vaccines. It's a college health center so I also make sure all of our nursing students have met their health requirements for clinicals. My days are pretty busy but I have to say I love my job. I have a lot of autonomy and my boss is a great teacher. I feel very fortunate to be there.

[SHGR, MSN, RN, CNS]

Our office runs very similarly to what Klone describes. Providers usually see 3 pts/hr; MA's do the exact work she describes. MA and RN write a separate note as needed.

I briefly worked at a different office where each provider had 2 MA's each, but they took detailed histories, did screenings such as the PHQ, and each provider saw 4 pts/hr.

Both places, providers are responsible for the chart note and the visit summary that is handed to the patient.

[T-Bird78]

We're a smaller clinic but still have around 20 pts daily with 3 nurses and 1 provider. One nurse does take back (rooming, vitals, lung function; also pt education and other misc. tasks the doc needs, such as IM or breathing tx), one nurse does skin testing, and the third does injections and phones. We rotate these jobs daily. We have pts walk-in for allergy injections. The phone nurse checks the line every 30-60 minutes. All morning calls are to be handled by lunch, all afternoon calls are to be handled by 4:00. Our outgoing message states to allow up to 24 hours and messages left after 4 will be handled the next business day.

If you can't have one designated person sit at the phones, can you rotate it so the first person done with the morning pt load check the line before lunch (if Dr. Smith's last pt gets discharged 10 minutes before Dr. Jones' pt for instance, then Dr. Smith's nurse would check the line) and same in the afternoon. Divide and conquer, and get all involved. If some aren't "good" at it, then give them the routine rx refills or normal lab results (better yet, have doc change policy to "no news is good news" so no call is needed for normals). Prior auths are so time-consuming. Can you stagger lunches to have one or two go to lunch at 11:30 and one or two stay to do some PA's? Good luck! Push come to shove, if pts start complaining to the doc that they had to wait 3 days for a phone call, maybe doc would hire a full-time phone nurse!