Physicians Who Don't Do Assessments

[1RN4Christ]

I am writing this somewhat heavy-hearted because what I felt needed to be done did not feel good, but needed to be said... If anyone can relate, I'd love to hear from you.

Recently, a patient I cared for passed away and I feel this death may have been preventable, or at least foreseen. An unfortunate series of events occurred with abnormals reported to the physician and a very non-aggressive approach was taken. This was the last straw for me and the action I've taken since is not a retaliatory effort.

I have noticed this physician write "notes" documenting the heart and lungs were auscultated in his patients, but while present in the room, I've never witnessed the stethoscope touch the patient. This is not the case with ALL the patients, just some. This doctor does not communicate much with nursing staff and disregards information others might find critical and gives no explanation so...I find myself referring to his notes to help piece together his idea of the presenting patient's clinical picture. After doing so, I've realized he has documented an assessment he did not do. I reported this.

As much as I think the physician is a nice guy and pleasant enough, that is no excuse for skimping on patient care. It's difficult to hear patients tell me "I just love Dr. So-and-So. He is just wonderful!" And while he can be, what he does from time to time, is not wonderful - it's dangerous. I can't shake what I know goes on on my side of the bed from my head.

Maybe it is a lie from the enemy to make me feel guilty about my decision to report this doctor. It's just unfortunate that while this greatly respected man goes about his business, I feel I have stabbed him in the back. However, I know, in reality, no one makes him practice the way he does. I almost wish I didn't know what I do so that it can stop eating at me.

Has anyone come across this issue or something similar? This is extremely sensitive and unethical and I realize, a very serious accusation. However, I can not ignore it.

-- Torn

[MunoRN, RN]

I will try to find a source, however, this is informational policy from my work with a CMS contractor, as well as information from the organization that I work with in regards to how CMS handles what they cover. Those policies may not be available to the lay person.

These are their policies: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

[LadyFree28, BSN, LPN, RN]

These are their policies: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

I am aware of their polices; however, unless you have done chart reviews, most people are unaware of what it takes to capture reimbursement in terms of documentation; those are ENTIRELY separate criteria that a reviewer follows in order to capture reimbursement. Documentation must be clear; however, in the sake of the thread; AGAIN it has been alluded that a physician DID NOT assess; and that is fraud; it's an issue that CMS has been really cracking down on...and more important the OP's issue is regarding how the physician's inaction may have (or did) not help the patient at all. That's the issue at hand.

[MunoRN, RN]

I am aware of their polices; however, unless you have done chart reviews, most people are unaware of what it takes to capture reimbursement in terms of documentation; those are ENTIRELY separate criteria that a reviewer follows in order to capture reimbursement. Documentation must be clear; however, in the sake of the thread; AGAIN it has been alluded that a physician DID NOT assess; and that is fraud; it's an issue that CMS has been really cracking down on...and more important the OP's issue is regarding how the physician's inaction may have (or did) not help the patient at all. That's the issue at hand.

Again, there is no "separate criteria", the link above is the criteria.

[LadyFree28, BSN, LPN, RN]

Again there is no "separate criteria", the link above is the criteria.[/quote']

My response IS about the criteria posted; again, there are STILL people who don't adhere to the criteria; there a still people who believe that they can just get away with billing ONLY and don't have documentation to back it up. I had to deny MANY physicians trying to capture an ICD-9 diagnoses of diabetes when there was discussion of hypertension only in the visit...that is NOT flying these days per CMS, and it hasn't for over 6 years; also, there STILL needs to be some note of discussion; AGAIN, I am not going to discuss with someone the criteria especially if one has not done Medicare Chart reviews, the BIGGER issue is that we are supposed to be discussing the OP's post.

That is a FAR greater issue than discussing something that one way have not done and can look on a policy about documentation but still have NO idea on how the application of the criteria really works.

Unless you have done the application of the criteria as I have done, and continuing to deal with on a daily basis, even in a facility (they have educated nurses in what constitutes appropriate documentation for Skilled nursing in my facility) I am DONE discussing this and contributing to the derailment of the thread.

Back to the OP's issue...thanks!

[1RN4Christ]

In my case, I KNOW rather than ASSUME this physician writes notes without touching the patient. He is only on the floor once during the day and literally, what I see is what I get - and it isn't much! Thank you for the information. :-)

[1RN4Christ]

Sorry, this response was for Guide. Still new at this posting thing.

[1RN4Christ]

THIS...

I've had as a CMS reviewer bill for the lowest amount due to the exact points Juan pointed out.

To the OP, I think that your decision to speak up was valid if the doctor is not assessing patients and there were serious issues that occurred as a result; there's one thing trusting clinicans and other providers, but an objective assessment always needs to be made.

Thank you for your input!

[1RN4Christ]

LadyFree28

Thank you for trying to stick to my post. THAT is my biggest concern and something I find TRULY bothersome. Btw, there were no vital signs documented on this patient either. Not from the day of the event or the day after when she remained extremely hypotensive and tachycardic. It read Lungs CTA, HRR.

[LadyFree28, BSN, LPN, RN]

LadyFree28 Thank you for trying to stick to my post. THAT is my biggest concern and something I find TRULY bothersome. Btw there were no vital signs documented on this patient either. Not from the day of the event or the day after when she remained extremely hypotensive and tachycardic. It read Lungs CTA, HRR.[/quote']

And that was FAR from what your assessment was; that IS concerning...if the physician did to an assessment, they would've at least approached you and tell you what the assessment was.

Depending on the area that you are in, especially in LTC, a lot of times providers get vital signs that are documented by the nurse; they will review that information and then do an assessment and follow up with the nurse somehow.

[Umberlee]

We have a doc who is really great about giving orders for whatever it is we ask for...but when it comes to actually doing his due diligence with patient evaluation, yeah, not so much. It works decently as long as you have a tight, cohesive team comprised of nurses with excellent communicative and assessment skills. If you have a nurse asking for stupid stuff with no basis in actual necessity, though, he'll just say sure sign off on whatever. We have six patients on nystatin powder for this reason. ANYWAY, I was working the other day when he came in to do an annual physical on one of our guys. He waltzed in, said hi to the resident, barely made eye contact with either of us, asked how he was doing (pt is barely verbal), didn't have a stethoscope or anything on him. Kind of patted the pts head and said, "Looks like you're doing great," and left the room. I was actually right in the middle of wound care on this pt, had just packed the dsg and asked the doc did he want to take a look at the wound real quick while he was in the room--he said "no thanks" and headed out. !!!