Mrs. PAC Posted October 12, 2012 Share Posted October 12, 2012 When do you deny medication refills on a patient that hasn't been seen in a while? Where does liability come into practice at this point? Is there a general rule in your office? Also, we do not have EMR and have the MAs pull the charts with the refill requests. Should they be looking in chart and determining which patients they should automatically call since it has been at least a year that they haven't been seen? Our office is a little unorganized and as a PA im do a lot of work that the MAs should be doing. Can anyone please send me a short protocol that works in their office. It would be greatly appreciated Link to comment Share on other sites More sharing options...
Guest Paula Posted October 12, 2012 Share Posted October 12, 2012 No refills if the patient hasn't been in for a year. My clinic does not have EHR either. THe nurses pull the charts and notify the practitioners if the patient hasn't been seen for 6 months or longer. I will not renew meds for a patient I have never seen, neither will the doctor who works at the clinic. If the patient was started on a new med, i.e. b/p med, and I have requested they follow up for recheck of b/p within 1 month, and they don't, I will give one months refill with a note to pharmacy no more refills until patient is seen.. If thyroid meds are needed and it's been more than one year since TSH checked, then 1 month supply is given and the patient is told they must have a followup lab and exam. Your clinic will have to decide your own "rules". Controlled substances are a whole 'nuther ballgame. You will need a protocol set up for your clinic for them if you want to keep any control! Link to comment Share on other sites More sharing options...
CAdamsPAC Posted October 12, 2012 Share Posted October 12, 2012 When do you deny medication refills on a patient that hasn't been seen in a while? Where does liability come into practice at this point? Is there a general rule in your office? Also, we do not have EMR and have the MAs pull the charts with the refill requests. Should they be looking in chart and determining which patients they should automatically call since it has been at least a year that they haven't been seen? Our office is a little unorganized and as a PA im do a lot of work that the MAs should be doing. Can anyone please send me a short protocol that works in their office. It would be greatly appreciated Good practice of medicine is the basic requirement. Patient's not following up with prescribed therapy falls onto their shoulders. You must communicate and document the expecations of your practice for chronic care/medications. When and if the patient elects to ignore the standards, so be it as long as you have documentation to support your actions. I may give a one week supply of Beta blockers or anticonvulsants with the stipulation the patient have a complete clinic visit within that week, again documenting this in the chart. Refilling chronic narcs are a no-go in "Clarkland"! Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 13, 2012 Moderator Share Posted October 13, 2012 you can NOT just stop prescribing with out giving the patient a chance to jump through the hoops to get refills for meds that there is no danger of stopping - ie thyroid, cholesterol and "some" of the HTN..... one month refill if not seen in a year and they have to follow for those meds wit danger to stopping - narcotics, benzo's, high dose Beta's.... you just can not stop writting - in Benzo's if you cut someone off you could kill them, in narcotics the withdrawl is not officially dangerous - UNLESS you have a cardiac patient. These patients - get verbal notices, then written letters, then written letters with tapering schedules only time you can really cut someone off a dangerous med is if they are selling it.... and even then you better be really careful honestly it is easier to fire them for non-compliance... Link to comment Share on other sites More sharing options...
Contrarian Posted October 13, 2012 Share Posted October 13, 2012 In many circles and in some states, it is considered unethical and "professional misconduct" to prescribe ANY medications without seeing the patient. Why...??? Because EVERY thing we prescribe has effects/affects and unwanted but sometimes useful side effects. It is our responsibility to monitor/mitigate/propagate these and to evaluate any care we initiate/prescribe to ensure effectiveness or reduce harm. My typical habit is to write for 30 days with 2 refills (3 months) for most medications or 90 days with 3 refills for mail in. The longest I usually prescibe/refill any non-mail in medication for is 6 months. So I have no patients that I don't lay my hands and eyeballs on atleast twice a yr. This has allowed me in several instances to discover hypotension (meds/bleeds), Cancer, goiter, recent MIs, TIAs, pregnancies (change teratogenic meds), Poly Substance Use, etc... Unlike above... I don't ascribe to the paternalistic and often "enabling" notion that I have to allow patients to use me and my DEA # as a tool while they blatently disregard my instructions. If they want a refill... then they need to make an appointment and show up. I have a responsibility to examine them and evaluate the effectiveness or ineffectivenes or harm of ANY and ALL treatment I pre/proscribe. If they exercise their god granted right of patient autonomy... and decide not to show up... then they have made a personal decision not to get a refill. Its that simple and really has nothing to do with me. I practice Internal Medicine, Psychiatry and my private practice is in Addiction Medicine and Chronic Pain. I interact with a LOT of patients with substance use disorder and ALL the behaviors that accompany this. I REGULARLY/weekly have Benzodiazepine addicts pull the "I know that it's friday at 4:40pm and I've missed 2 appointments with you and its a week early for my refill, but I'll go into seizures if YOU don't refill my [insert drug here]"... I usually launch into my "motivational interviewing" mode... I listen intently, validate their concerns, help clarify what their verbalized treatment goals are and as soon as I hear the "readiness for change" door open... I encourage them to be a bit more anticipatory, proactive and forward looking instead of reactive in managing their health and instruct them to make an appointment to be seen ASAP, then let them know that I won't be re-filling that requested medication but I'll be calling in a Rx for them to the pharmacy for a anti-convulsant (depakote/carbamazepine/keppra/Gabapentin) and a bite block...:heheh: Simply put... In these situations, its usually the patient not the prescriber who puts the patient's health at risk by making the decision to disregard the instructions of the provider. If a patient has a seizure from Benzo withdrawal... it will be because they didn't refill their medication. They ALL know, to do so, with few exceptions, they have to have been seen by me within the last 60 days... Link to comment Share on other sites More sharing options...
uscbigdawg Posted October 13, 2012 Share Posted October 13, 2012 Army side, we would not renew Rx's if we hadn't seen you per any recommended follow up notes (nice way of saying case by case). That said, while I'm not against giving out narcs, I do have a good memory of when I saw someone last and in general if they were given narcs. However, it's annoying when I've seen practitioners freely dispense them with little to no real assessment of the patient. Once upon a time, I worked at an urgent care center and I screened a patient that was a textbook narc seeker. I pulled her last four visits and in all instances was given good amounts of pain meds. I addressed with the Doc on duty including noting the patient's behavior prior to the office opening, in the waiting room and the show that ensued when I began my assessment. His stance at the time was, cash patient = $100 office visit for 3 minutes of work and wrote the Rx. I then contacted some "friends," from my youth to get the word on what folks on the street knew about our clinic. Frankly, we were Burger King in there eyes (your way, right away). I left soon after that. Rich Link to comment Share on other sites More sharing options...
CAdamsPAC Posted October 14, 2012 Share Posted October 14, 2012 In many circles and in some states, it is considered unethical and "professional misconduct" to prescribe ANY medications without seeing the patient. Why...??? Because EVERY thing we prescribe has effects/affects and unwanted but sometimes useful side effects. It is our responsibility to monitor/mitigate/propagate these and to evaluate any care we initiate/prescribe to ensure effectiveness or reduce harm. My typical habit is to write for 30 days with 2 refills (3 months) for most medications or 90 days with 3 refills for mail in. The longest I usually prescibe/refill any non-mail in medication for is 6 months. So I have no patients that I don't lay my hands and eyeballs on atleast twice a yr. This has allowed me in several instances to discover hypotension (meds/bleeds), Cancer, goiter, recent MIs, TIAs, pregnancies (change teratogenic meds), Poly Substance Use, etc... Unlike above... I don't ascribe to the paternalistic and often "enabling" notion that I have to allow patients to use me and my DEA # as a tool while they blatently disregard my instructions. If they want a refill... then they need to make an appointment and show up. I have a responsibility to examine them and evaluate the effectiveness or ineffectivenes or harm of ANY and ALL treatment I pre/proscribe. If they exercise their god granted right of patient autonomy... and decide not to show up... then they have made a personal decision not to get a refill. Its that simple and really has nothing to do with me. I practice Internal Medicine, Psychiatry and my private practice is in Addiction Medicine and Chronic Pain. I interact with a LOT of patients with substance use disorder and ALL the behaviors that accompany this. I REGULARLY/weekly have Benzodiazepine addicts pull the "I know that it's friday at 4:40pm and I've missed 2 appointments with you and its a week early for my refill, but I'll go into seizures if YOU don't refill my [insert drug here]"... I usually launch into my "motivational interviewing" mode... I listen intently, validate their concerns, help clarify what their verbalized treatment goals are and as soon as I hear the "readiness for change" door open... I encourage them to be a bit more anticipatory, proactive and forward looking instead of reactive in managing their health and instruct them to make an appointment to be seen ASAP, then let them know that I won't be re-filling that requested medication but I'll be calling in a Rx for them to the pharmacy for a anti-convulsant (depakote/carbamazepine/keppra/Gabapentin) and a bite block...:heheh: Simply put... In these situations, its usually the patient not the prescriber who puts the patient's health at risk by making the decision to disregard the instructions of the provider. If a patient has a seizure from Benzo withdrawal... it will be because they didn't refill their medication. They ALL know, to do so, with few exceptions, they have to have been seen by me within the last 60 days... No disagreement here "C" you have eloquently stated my view and position on THE PATIENT'S RESPONSIBILITY to comply with treatment. Link to comment Share on other sites More sharing options...
Mrs. PAC Posted October 16, 2012 Author Share Posted October 16, 2012 Thank you for all the replies. I do not write many controlled substances and so that is not a problem for me. The rest of the day to day meds were my main concern but I definitely received an abundance of great feedback. How do your offices handle referrals and medical records? Does the Ma handle all medication authorizations? Is it their responsibility to go through chart and answer questions on the forms? I would love if I can get feedback on how other practices are run so I can help organize mine. Thank you so much :) Link to comment Share on other sites More sharing options...
rcdavis Posted October 16, 2012 Share Posted October 16, 2012 Where I occasionally moonlight, all patient call ins, requests for Meds refills, etc plus new lab and X-ray reports, have record pulled, call in form/ pt request form or labs/X-ray report, or consultant letter, attached to it. Then the pile is gone through by the practitioner during the day.. With written instructions for the nurse/ma. These instructions may be "call in refill Mobic 15 mg #30, one qd", or "tell patient labs look much better than before, continue taking her Zocor" or "cannot refill this med right now, ask patient to come in in the next day or two for evaluation". The data is then filled with the record, so there is a paper trail. For emr, the e-record is put into our daily incomplete record file, with nursing or front office notation of the call, and answered electronically, with the above notations made as nursing orders. Of course, if we call ourselves, same thing applies. Link to comment Share on other sites More sharing options...
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