ddiaz4 Posted September 7, 2018 Share Posted September 7, 2018 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. Quote Link to comment Share on other sites More sharing options...
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