Physician compared to nursing documentation

[DebCGH]

We have recently implemented T-system template documentation for our ER physicians. The physicians had been used to a joint form which blurred the lines of who should do what type of documentation: RN or MD. Some RN charting was seen as medical screening partially leading to the decision to go to T-system. After 4 weeks of using the system, the physicians want the nurses to complete the reason for visit and past medical history portion. They feel that since nursing already asks these questions, the physicians should not have to duplicate this information. Secondly, per T system recommendation, the physicians pull their own templates. As one physician just said, When I come in at 2am, it would be nice to have that sheet ready for me to fill out.

My question to you:

If you use T system at your facility, who pulls the templates for the MD. Does the nurse complete any documentation on the physician template?

If you don't use T system, on your system, is the nurse doing any documentation on the physician form? If so, is this area easily identified as a nursing area or is it blended?

Lastly, I work in clinical informatics -- I am an RN -- and was pulled into this project as the nursing area will eventually be charting electronically. So my knowledge base of ER physician documentation regs/rules is very limited. Can someone suggest where I can get good information on what they should be charting?

[canoehead, BSN, RN]

If the physicians choose to copy from RN notes they are more than welcome to do so. As we all know most patients wind up being more forthcoming with the doc than with the triage nurse, so I would recommend the docs do their own screening.

[traumaRUs, MSN, APRN]

I'm an APN in an ER that ues T-sheets. The nurses pull the T-sheet for us and we fill everything in completely.

[Larry77, RN]

I've worked in some dept's where it was the Docs responsibility to pull their own templates but the RN's did it anyway. If they c/o which one you pulled they would be reminded that they are technically supposed to pull them.

We use the electronic version of T-system...much better than the T-sheets INMO...very easy to use.

[mwboswell]

I'm a NP in an ER that uses IBEX/PICIS (not a T-sheet; but we USED to!)

The RN's and NP/MD's share the SAME: Medical, Social, Family, Surgical history sections.

I do not know what the policy requires of the RN's to chart in these areas, but often times they do gather this history and we (providers) can see what they've entered.

We can choose to check a box for each that says "reviewed RN documentation" or "agree with RN notes" and this gives us credit for the appropriate level exam for billing purposes, HOWEVER,

the "wise" provider reviews all this and asks these questions themselves also.

There are SEVERAL instances where the info the RN entered is incorrect or inappropriate and has to be corrected.

I NEVER check the box that says "agree with RN notes"...I use the "reviewed RN documentation" instead as this doesn't imply "agreeing" with it.

-MB

[Lunah, MSN, RN]

We just switched from the T-system to PICIS (electronic) in June, but prior to that, the docs/PAs pulled their own T-sheets, and did their own documentation. The only time we pulled their T-sheets was if it was something like a stroke pt., in which case we'd pull a whole packet that included the physicians T-sheet. (Kept typing t-shirt there. Arrgh.)

With our PICIS system, it's as MB said -- we do the history section, and the docs/PAs review it and add to it if necessary (you know, like when the patient says, "Oh yeah, I forgot to tell the nurse I had a heart attack with stents placed last week." ).