SP Findings Documentation

[ddiaz4]

Posted this in wrong area earlier!

 

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. 

[beattie228]

On cases I've discussed with SP, I'll write a generic "Treatment plan and medical decision making was discussed with X who agrees with the above".

 

I do that for every case I run past an SP, although I'm 99% autonomous so it's few and far between for me. I'd discuss it with your SP's to see what they'd like you to do. If the case was run past them, that should be reflected in the chart in my opinion.

[Joelseff]

On cases I've discussed with SP, I'll write a generic "Treatment plan and medical decision making was discussed with X who agrees with the above".  

I do that for every case I run past an SP, although I'm 99% autonomous so it's few and far between for me. I'd discuss it with your SP's to see what they'd like you to do. If the case was run past them, that should be reflected in the chart in my opinion.

 

Something like this and make sure the SP CO-SIGNS IT!  

I do this with ANYONE I consult with on a specific case.

 

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[ddiaz4]

Thank you so much.  Im being treated like this is an insulting practice!

[sas5814]

I document it but I never ask for a counter signature. I get fairly specific. "Dr Blah agreed than >med< and >med< were appropriate treatment."

I mean really.....do you want to work for someone who agrees with your plan and then flips on you later? That is no kind of professional relationship. If I have to get a fingerprint on my notes I'm in the wrong place.

[ventana]

Doc is higher license - they get paid more, and are higher on the totem pole

 

if they tell you do something document that you had d/w them and this was their decision

[Joelseff]

Doc is higher license - they get paid more, and are higher on the totem pole
 
if they tell you do something document that you had d/w them and this was their decision

That's why I get them to co sign so they can't double back and have their (high and mighty) word against mine.

Been burned before. Learned from it.

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[beattie228]

9 minutes ago, Joelseff said:

That's why I get them to co sign so they can't double back and have their (high and mighty) word against mine.

Been burned before. Learned from it.

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Same. I get a co-signature on 100% of patients I chat about. Can't argue about a computer generated signature that confirms they were involved.

[Reality Check 2]

If the SP mandates a tax plan that doesn’t follow guidelines or seems inadequate — document that Dr Bozo DETERMINED plan to be ******* whatever after discussion and those orders were placed on his/her DETERMINATION. 

If an SP is going to dictate treatment - give them credit..... 

If you are treating something and want to say where you got it - say it. Cat bite treated per current recommendations in Sanford’s.  UTI tx’ed based on regional health dept resistance listings. 

If you really don’t like their plan - enter it for THEM TO SIGN. 

MD does not mean Medical Deity.

[ddiaz4]

21 hours ago, ventana said:

Doc is higher license - they get paid more, and are higher on the totem pole

 

if they tell you do something document that you had d/w them and this was their decision

I totally agree and have no problem with following the plan of someone with more experience than myself and whose license Im under, just want to make sure Im able to document in a respectful way that the final decision was someone else's and this thread has verified that this is common and correct practice, thus making the way I write these notes more defensible in my mind. My end goal is to protect everyone's license, especially mine. 

[Joelseff]

I totally agree and have no problem with following the plan of someone with more experience than myself and whose license Im under, just want to make sure Im able to document in a respectful way that the final decision was someone else's and this thread has verified that this is common and correct practice, thus making the way I write these notes more defensible in my mind. My end goal is to protect everyone's license, especially mine. 

If you're SP is resisting, contact your legal or your risk mgmt dept and get documentation guidelines. If you are private practice maybe ask your insurance carrier. Also emphasize that it protects "Everyone's license" as you put it. My CP/SP's have never had a problem with it.

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[ravenspac]

On 9/7/2018 at 11:08 AM, beattie228 said:

On cases I've discussed with SP, I'll write a generic "Treatment plan and medical decision making was discussed with X who agrees with the above".

 

I do that for every case I run past an SP, although I'm 99% autonomous so it's few and far between for me. I'd discuss it with your SP's to see what they'd like you to do. If the case was run past them, that should be reflected in the chart in my opinion.

agree.

 

Case was reviewed with XXX. He helped formulate and approves of the plan.