Phsycian Refusal to write med orders

[Luv Nursing]

Hey ya'll,

I'm actually an acute unit manager but I'm having difficulty with a physician that involves LTC. This physcian refuses to write medication orders on the In-patient hospital physician discharge orders form. He writes next to the medications the word "Recommendations". His take is that by law, he can not write orders for a patient where he does not have privleges.

This comes up every few months or so (and then he complies until he gets a bug up his bum). Each time he is told federal regs state LTC must have the discharge summary,(which we have always used the discharge orders) with the patient's medications or they can not take the patient. I've repeatedly tried (as the Medical Director has explained to him as well) that he is writing discharge orders from the hospital (as if he is going home) and not admission orders to the Nursing Home Facility.

Today we went 10 minutes on the phone with him telling me literally that everyone else is wrong and he is interpreting the regs correctly. He asked me what it was the LTC facility wanted specifically, and I told him the word "recommendations" could not be on the form. I told him regardless of his feelings and even if we are all wrong, the patient has not left the floor and will not go to a nursing home as his physician discharge orders stand.

Can anyone help me out? Any specific regs regarding this, better way to explain this? I'm dreading tomorrow morning because if he doesn't round on the patient he knows is here, we'll have another issue to contend with.

Appreciate your help greatly!

Also, due to renovation, we have Rehab patients on our floor now so we have Acute hospital regs and LTC regs (which we know nothing about and have had little inservice to help us) to contend with as well. If anyone has some good links or info I could look for LTC help with I'd appreciate it even more!

[UM Review RN, ASN, RN]

Go over his head to the Medical Director or Director of Physicians at the hospital. Explain that you've had this problem in the past, attempted to remedy it, and the results.

Everyone has someone to answer to. At our facility, if he doesn't comply with our P&P's, he can lose privileges. He needs to realize how much the hospital has to shell out for every extra day that patient is there.

[lpn1313]

Tell him he's not writing orders for the LTC. All hospital orders must be verified by the LTC doc taking over the care of the resident. They write the orders, not him. They also can and do change orders that they don't want. Even our residents that have consults with specialists have to have orders verified with the house doc. I've never seen a doc write "recommendation" for anything.

[Luv Nursing]

Thank you to everyone who's given me some great suggestions. Please keep them coming. I had already spoke to the Medical Director, the Medical Director had spoke to the Physician, and unfortunately, our Physicians are rarely (if ever) "forced" to do anything. The CEO takes an active "do not deal with it" approach with everything and everyone.

The medical director is contacting our lawer regarding this (by the way, our CEO is our Risk Manager...how appropriate and effective is that?!) and I'm going to contact our local LTC's and see what they receive in the form of paperwork from patients discharged from other hospitals.

Any more suggestions, I'm listening. And thank you again!!

[Talino]

Hosp. MDs write a discharge summary. Unless a patient is discharged home, they do not prescribe meds or ttts for the accepting LTC to carry out. If they do, a "recommendation" is likely what it will be called. A "list" of meds & ttts is attached to the DC summary, along with a copy of labs/xrays, procedures, consultations, etc.

Unless the same hosp. MD will be the LTC MD, the admitting facility is responsible for assigning a physician to care for the patient. The meds/ttts received while in hosp. and recommendations will be reviewed (albeit, most often, followed through). Nonetheless, only the LTC MD orders, ultimately, will be carried out.

The LTC regs can be found here - http://www.cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf

see...

• 483.20(a) Admission Orders
  
• 483.40 Physician Services
  

Since your facility is licensed as a hospital, you abide by the same regs, regardless Rehab patients are roomed-in.

[Luv Nursing]

Dear Talino,

Outstanding and THANK YOU!!

[CapeCodMermaid, RN]

In Massachusetts. we need a discharge summary AND the PMOS...physician's medication order sheet. Legally we do not have to accept a patient without either of these two forms. I've never seen a patient sent back, though, because the paper work was missing.

The discharge MD must write orders for his/her patient regardless of who is following them at the SNF. The MD covering the patient at the SNF can say yea or nay to the medications.

[Reigen]

At the facillities where I have worked, sometimes the new Residents has arrived with less than stellar orders. In those cases we either call the physician who wrote the orginal orders for clarification, and any other orders that might be needed, (examples: Tylenol for temp above 100, or headache, MOM 30 cc for no BM x 3days, any other "standing addmission orders"), or we call the facillity Medical Director for those orders.

If the physician that wrote the discharge orders will NOT be the attending at the LTC facilliy, it is the facillity policy that the new attending do a resident visit/physical within 4 hours, or the Medical Director shall be called.

Having to call the Medical Director and informing that a new addmission is "here and awaiting he addmission physical", has happened a few times.

I love hearing about "being called AWAY from m priviate practice", because "someone" couldn't wouldn't should have written a few orders.

Our Medical Director informs the discharging physician what is needed to comply with Federal and State Regs. for long term care addmissions. That is part of the job of being the Medical Director, we have found that it goes better Docotor to Doctor, and this has saved the nursing staff countless hours of fustrations.

I hope that your problems is sloved quickly and that you get a policy/proceedure to have it stayed solved for the future.

Reigen

[achot chavi]

My recommendation is to keep a diary of the problems you are having with this physician and the conversations/ requests you have had to have with him just in case he turns the tables and complains about you.

Keep all conversations with him professional and not personal- try to do it in front of other people if you can- for witnesses.

I would also do an official audit on all the other physicians on the unit and what their practices are in this issue so you have black on white that this physician is out of sync. I'm not saying that you have to ask these other doctors to write anything- just ask them and record their answers.

I would never pick up an order that is just a recommendation rather than an official order- properly written and all. If I see my nurses doing it - I warn them then to write them up if they continue to accept improperly written orders. It never happens anymore.

You might want to ask the in-house attorney if this physician is correct in his accusation that he is the only one doing it right and the others are wrong. If you can get something in writing from the attorney that is even better.

Also if he sometimes does it one way and sometimes the other - that really weakens his argument that his way is the right way!!

BTW in our facility many patients come from home with a self-handwritten note of medications that they currently take - and our medical director has to go digging in old hospital records and call the last known doctor for a more accurate list.. What always amazes me is that the patient says- what- don't you trust me???

We had one 90 yr old who insisted that he takes Viagra on a regular basis....

[CapeCodMermaid, RN]

You didn't believe the 90 year old who took Viagra? I have had plenty of really elderly male patients taking Viagra when they are at home. We don't order it in the facility of course unless they are going to be there long term and want conjugal visits.