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Documenting physician findings

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Hello everyone,

New grad in UC. Wondering how best to document SP decision after a discussion on therapy. Recently had one of my SPs gift me a new bumhole because I documented he chose to treat with only one of two medications we specifically discussed per a current guideline. How do I ensure that the record reflects his final decision and also protect myself if someone ever asks me why I didnt cover for something? Another case recently was a patient with sob and rhonchi that another SP didnt feel would benefit from bronchodilators: shouldn't such a decision merit specific mention of this decision? Right now unless I specifically say so, the chart doesnt reflect that pretty much everything I do is the SPs decision. Its a new position and right now I am more scribing than practicing medicine. 


Edited by ddiaz4
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If they are making the decisions, they can write the note/sign the chart.  Then it's on them.  

As a new grad I'm easing into it with shared visits so the SP has to do an attestation/state their findings so they are just as much part of the note as I am.

Otherwise, their feelings be damned.  If SOP calls for treatment A and they pick treatment B, you need to document why.  If something happens down the line, your name is on the chart and if it's not documented, it didn't happen and I get the feeling these SPs won't be coming to your rescue.

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  • 7 months later...

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