Thoughts on co-signature

[Avalon]

Good Afternoon,

 

I wonder if anyone has thoughts on this situation. I'm not sure if I am comfortable or uncomfortable, vulnerable or not, or professionally appropriate or not, in representing my field.

 

I have recently added two days per week in OB/GYN at a different location from my family medicine position. The new position allows me to (finally) explore and develop my passion for women's health, and I am dleighted to have found this opportunity (despite my now six day work week). The practice consists of one OB/GYN with nearly 30 years of experience, and his NP/CNM partner of 12 years. I am at the moment only doing gynecology in this practice, with the expectation that I may expand into obstetrics if things go well.

 

This office has never employed a PA before, and I have learned in my three brief weeks to date that there have been at least a few failed attempts to bring another midwife or women's health NP into the group. Thus, I feel as if I am on a probationary period of sorts, which is perfectly understandable. Because of this, I wish to tread cautiously.

 

This position is in a state neighboring the one in which I live and practice family medicine. I have had to secure a second license and file a delegation agreement with my new SP; in the course of this long and cumbersome process, I have become quite familiar with the laws governing PA practice in the new state. There is no requirement for physician co-signature of charts. I have noticed, however, that the NP/CNM (she has both certifications) has been reviewing and signing all of my charts. I like her and respect very much; she is bright, skilled, and supportive of me, while my SP essentially ignores my presence.

 

Since legally no SP signature is required, I'm not concerned that he is not reviewing my charts. I have also noted that this NP/CNM co-signed the charts of some of my predecessors in this position, so perhaps it has always been seen as her role to oversee the work of the new practitioner(s). I value her insights and her mentorship and am personally pleased that she is taking an active interest in the care I am providing. I have already learned some subtleties of the art of women's health from her. I suppose I just feel a bit uncomfortable because it appears that a NP/CNM is "supervising" me as a PA, and my SP of record rarely communicates with me. I should note as well that this is a state that gives autonomy of practice to NPs.

 

Any thoughts are welcomed. Thanks in adavance.

[Contrarian]

Not a big deal... as long as you can demonstrate that you meet the supervisory requirements of your state BOM/PA board. There are lots of practices that employ both PAs and NPs then promote one of these professionals to serve as "Lead." I've worked places where the immediate supervisor was a NP and responsible for clinically mentoring all other Non-Physician providers. I've also worked places where this person was a PA. Worked at one place where the "Medical Director" was a NP and responsible for disciplining hiring and firing all the MDs/DOs, NPs, PAs.

[rcdavis]

I agree with contrarian, with one hesitation.

 

I would be upfront and ask her frankly: "I noticed that you were countersigning my records... I was wondering in what capacity are you doing that?"

 

I suppose the only appropriate response , at least for me, would be " until dr x and I feel comfortable with your practice, we as a practice will ge countersigning your charts to demonstrate appropriate over site over a novice ( to GYN).." and "this is a temporary arrangement"

 

I do not agree that the NP should be in any way countersigning your records as a supervisor.. She is NOT Your supervisor, unless tere is something I missed in your post.

 

I have been a senior PA for several years and had many junior PAs.. And reviewed many charts. I never countersigned any of these charts unless there was an administrative requirement to do so.. Usually facility specific.. And this was always explained to the PA what the purpose was...

 

I truely fail To see any advantage to anyone having the NP sign the chart... Unless she has been designated a reviewer and the MD wants that documentation.

 

If she is your medical supervisor.. Rethink your position.

 

Under NO Circumstances should a PA be subordinate to an NP.

[Contrarian]

Under NO Circumstances should a PA be subordinate to an NP.

In the "pure sense " of the word "Subordinate" ...NO....!!!! Otherwise I Strongly disagree... While I agree that a NP should NOT be considered the "SP" (Supervising Physician) of a PA for state licensing purposes... there are lots of instances where a NP can and should be the clinical or practice "Supervisor" of a PA. For instance... in this case, it appears that the NP has A LOT more clinical and GYN experience than the PA and it appears that the NP is a part owner of the practice.

The practice consists of one OB/GYN with nearly 30 years of experience, and his NP/CNM partner of 12 years.

As I said above... I think its rare but there are some situations where the NP has the identical scope of practice coupled with the EXPERIENCE to serve as a clinical supervisor for a PA. This was surely the case when I first started in Psychiatry and the "Medical Director" of the rather large Mental Health Organizations I worked for was a Psych NP with 30+ yrs of clinical Psych NP experience. Yes there were a few physicians around, and they were used/listed as my "SPs" on the state paperwork... but it was this NP who served as Medical Director and from whom we all (PAs/NPs/MDs/DOs) took direction from. it was NOT a issue... as she was well aware of her training and the limitations that entailed and never tried to direct anything but "Psychiatric Care." So yeah... there ARE some instances where PAs "supervising" NPs and NPs "supervising" PAs is appropriate. Obviously this opinion is shared by others since lots of PA students have found themselves following NPs on certain rotations.

[ventana]

hummm tough spot

 

I for one would not be wanting to sign someones chart like she is doing - all she is doing is opening her self up to liabilty - I see C's point, but I think it would be better to not have her offically signing the chart in an open sense. I would however try to learn everything possible from her - and document when you have spoken with her in the chart - that way you are putting her on the hook, instead of her claiming to be your direct line medical supervisor.

 

She is a knowledge source and for that I would learn everything possible, but I would avoid a tiered "the NP is always higher then the PA" type set up. This will end up being a point of contention as you learn, expand your knowledge, and get your own style of practice.

 

When an SP tells you do to something his/her way you do because they said so (even if it is against your own thoughts) and this is okay with the state and the SP, but what about a NP that tells you to do it a certain way 3 years from now when you are both right? That would be an ugly situation.....

 

So I would propose having her keep a list of charts that she has reviewed but having a time frame on which this "informal supervision" ends - ie 500 patients or 6 months........ that way both of you know there is an end to the situation and that she is only pinch hitting due to having extensively more experience, but as you gain your own base you are free to practice as you see fit.

 

Would likely also propose a phase 2 - from 6-->12 months where you will review 1 case a shift or some other agreed on number, with her, in place of the direct chart review......

 

 

Honestly, I am surprised she would want to put herself on the legal liability hook so freely......

[3GeronimoPA]

Agree with you there Contrarian. If she is reviewing the work as a means to help assess and improve you "initially" not so big of a deal. If she is a partner/part owner etc. and you being good or bad has implications for her organization, I say no big deal. If she just has a lot more experience there should be a goal in mind as to when you can function at the level of a normal PA or NP in that position. The only thing I'd caution you about rcdavis' suggestion is to not confront the Nurse. Talk to your boss and just mention, "Hey I saw so-and-so cosigning my notes. What is the interaction expectation with my role and hers? Is she a mentor, supervisor, or just a quality control for me until I get proficient enough for you to feel comfortable?" And don't ask those questions without a planned answer/response in the event of each one so you don't make any hasty decisions. If a PA ran a business that was beneficial for me to work for him, I'd do it at the drop of a hat just as I would for a MD/DO or an NP for that matter. If that person running the business wanted to cosign all my notes, I wouldn't bat an eye. Now if the intent was for your notes to always need cosigning and that was to be done by a person of equal scope who was not your boss or SP, I wouldn't do it just as a matter of principle.

[EMEDPA]

I have no probalem with a pa or np acting as lead over the other. at a prior job I was lead over 12 PAs and 2 NPs. like Davis I never signed anyone else's chart unless I was involved in the care, took a sign out, or did a procedure, etc.

I would not want an np signing my charts. reviewing, sure, but not cosigning. ditto another pa.

[Guest JMPA]

I have the janitor co-signing my charts. That will stand up in court, right?

[EMEDPA]

I have the janitor co-signing my charts. That will stand up in court, right?

only if it is this guy:

 

[Teasip]

I concur with the perspective of it being a potential liability for the NP. Unless expressly stated in an office P&P manual, why would one wish to take on the added liability as a result of having ones name on the chart? Review the charts unofficially, even keep a review log if one wishes, but don't put your name on the chart.

[Contrarian]

Oh...

I agree that the NP is taking on more liability... but that's also true by virtue of the fact that the NP is also a "Partner" in the Practice.

 

So if ANY "employee" of that practice does something that causes that practice to be sued, or even her partner (the Physician) to be sued... the NP WILL be affected . Tis the burden of a "business owner" ... so I'm really not sure what the issue is since we KNOW that the NP isn't the PA's "SP."

 

My questions is... Why do we even CARE that the NP has decided that she needs to open herself up to more liability...??

 

I suspect its more of the turff war... "PAs are inherently and ultimately better than NPs at everything" nonsense.

[ventana]

Oh...

I agree that the NP is taking on more liability... but that's also true by virtue of the fact that the NP is also a "Partner" in the Practice.

 

So if ANY "employee" of that practice does something that causes that practice to be sued, or even her partner (the Physician) to be sued... the NP WILL be affected . Tis the burden of a "business owner" ... so I'm really not sure what the issue is since we KNOW that the NP isn't the PA's "SP."

 

My questions is... Why do we even CARE that the NP has decided that she needs to open herself up to more liability...??

 

I suspect its more of the turff war... "PAs are inherently and ultimately better than NPs at everything" nonsense.

 

 

The NP is the same level of a PA, no medical supervision

 

Medical mistake made by the PA, the PA and the Doc are on the hook, not the NP

 

Business owners policy does not cover medical malpractice nor vise versa. By the NP signing the chart she is putting herself on the hook for med mal, which she would not have as an owner, only as a supervising provider. Now she is on the hook for the higher premiums for the med mal as the practice owner.

 

It is not about PA or NP being better, but instead the exact that NEITHER one is better nor higher......

 

large difference between med mal and Business owners general liablity policy and what is covered......

 

This is the ultimate difference from independent and dependent practitioner....

[Avalon]

Thanks to all for your thoughtful replies. Just a quick clarification: I am not certain of the business relationship between the SP and the midwife/NP. I did not intend the word "partner" to imply business partner, although I do think she may be a part owner of the practice. She has been with the SP for 12 years and her name appears on all forms and all advertising materials for the practice. She essentially handled all aspects of my hire, with the exception of negotiating my salary (which, as an aside, has become another entangled mess).

[Contrarian]

Sigh...

The NP is the same level of a PA, no medical supervision [really..??? NO... if I recall correctly... the OP stated that this is in a State where there is NP Independence... there is NO SUCH THING as PA independence]

Medical mistake made by the PA, the PA and the Doc are on the hook, not the NP [Duh... We know this already and was/is NOT a point of contention]

Business owners policy does not cover medical malpractice nor vise versa. By the NP signing the chart she is putting herself on the hook for med mal, which she would not have as an owner, only as a supervising provider. Now she is on the hook for the higher premiums for the med mal as the practice owner. [umm... shortsighted much...??? As a Co- BUSINESS OWNER... if the Physician is sued... she WILL suffer some repercussions. Whatever they are. Please tell me that YOU aren't naïve enough to actually believe that if YOUR SP/BUSINESS PARTNER gets sued... you will NOT be effected. ]

It is not about PA or NP being better, but instead the exact that NEITHER one is better nor higher......

 

large difference between med mal and Business owners general liablity policy and what is covered...... [Duh... as a business OWNER I'm well aware of this]

This is the ultimate difference from independent and dependent practitioner....

Even a group of "Independent" Providers can be negatively affected/effected if one of their partners get sued (although you have to take into account that the big pockets "shotgun approach" is usually employed whereas the PA/MD AND Practice entity (LLC/PLLC/Corp) is sued).... A oversimplified example of this would be 2 physicians (independent providers) who share overhead and split profits 50/50. If one gets sued and can't practice... the other physician has to pay for all of the overhead to keep practicing and that remaining physician also doesn't get to enjoy the 50/50 split of the profits of the other physician (can you say income decrease?)... simply put... if two independent providers decide to do a 50/50--> 24hr split and each of them worked 12 hrs... they would be making money 24hrs a day. Now if one of those physician was sued and couldn't practice (due to a error of omission/commission/negligence/etc)... the one still practicing would take a SUBSTANTIAL financial/Quality of life/Practice altering hit....!!!! Personally... if that NP is a business partner... I can't really see how this principle doesn't apply.

Dude... Do you actually read and THINK about what is being said BEFORE you post... or do you just respond...??? Geesh...!!!

[CAdamsPAC]

only if it is this guy:

 

 

He has signed my charts since I lost my arm.

[EMEDPA]

he has signed my charts since i lost my arm.

talk about a hostile sp....i will sign your charts even though you killed my wife!

 

[crank]

Hi Avalon,

Its great to hear about the passion on women health. Before starting anything, make use of agreements, because it acts as a tool for the success of the projects. For success they need to view your charts. Absence of Co signature doesn't mean that, they will not view your charts.

[ventana]

 

 

 

The NP is the same level of a PA, no medical supervision [really..??? NO... if I recall correctly... the OP stated that this is in a State where there is NP Independence... there is NO SUCH THING as PA independence]

 

 

YOU misunderstood my statement, the statement is that the NP cannot supervise the PA. Nothing in regards to independent practice intended

 

 

Medical mistake made by the PA, the PA and the Doc are on the hook, not the NP [Duh... We know this already and was/is NOT a point of contention]

Business owners policy does not cover medical malpractice nor vise versa. By the NP signing the chart she is putting herself on the hook for med mal, which she would not have as an owner, only as a supervising provider. Now she is on the hook for the higher premiums for the med mal as the practice owner. [umm... shortsighted much...??? As a Co- BUSINESS OWNER... if the Physician is sued... she WILL suffer some repercussions. Whatever they are. Please tell me that YOU aren't naïve enough to actually believe that if YOUR SP/BUSINESS PARTNER gets sued... you will NOT be effected. ]

 

you seem to miss the point - if the NP does not cosign the chart, she has no medical liability, obviously the business side of it with the partnership would be affected, we are talking medical liability here, by her signing the chart she is placing herself on the medical liability hook. Also your statements of negative effects to the Corporation are not really true. Typically the malpractice is paid by the Corporation and this would be the only increased cost and in many companies each provider's overhead pays their own malpractice insurance. In this case the 'profit' would only be minimally effected.

Please do not tell me that you are naïve enough to think that every owner of a corporation would be negatively affected with one getting sued..... Also there is no where on a malpractice insurance policy that asks if you have ever worked for a corporation who had been sued. If she doesn't sign she can only be sued as a business owner.

It is not about PA or NP being better, but instead the exact that NEITHER one is better nor higher......

 

large difference between med mal and Business owners general liablity policy and what is covered...... [Duh... as a business OWNER I'm well aware of this]

 

then why to you keep trying to lump medical liability, Business owner policy, and general injury to the Corporation all under one heading? I know you have owned a number of practices, yet you seem to lump everything together and any lawyer or claims adjuster is going to pick them apart as the very first step.

 

This is the ultimate difference from independent and dependent practitioner....

 

Again YOU misunderstood my first comment - PA's are dependent, the NP has no medical standing in this equation and therefore has not medical liablity unless she signs the charts.

 

Sigh... Even a group of "Independent" Providers can be negatively affected/effected if one of their partners get sued (although you have to take into account that the big pockets "shotgun approach" is usually employed whereas the PA/MD AND Practice entity (LLC/PLLC/Corp) is sued).... A oversimplified example of this would be 2 physicians (independent providers) who share overhead and split profits 50/50. If one gets sued and can't practice... the other physician has to pay for all of the overhead to keep practicing and that remaining physician also doesn't get to enjoy the 50/50 split of the profits of the other physician (can you say income decrease?)... simply put... if two independent providers decide to do a 50/50--> 24hr split and each of them worked 12 hrs... they would be making money 24hrs a day. Now if one of those physician was sued and couldn't practice (due to a error of omission/commission/negligence/etc)... the one still practicing would take a SUBSTANTIAL financial/Quality of life/Practice altering hit....!!!! Personally... if that NP is a business partner... I can't really see how this principle doesn't apply.

Dude... Do you actually read and THINK about what is being said BEFORE you post... or do you just respond...??? Geesh...!!!

 

 

your example is admittedly over simplified. Physician's continue to practice, practices continue to exist after suit, profits are continually made (hopefully). Unless the person is stripped of their medical license the practice continues with minimal effect.

 

I think you totally have overstated/oversimplified the issue in this case, however I am aware you tend to have an inability to admit this.

 

 

 

In summary, the nurse practitioner has no medical liability unless she signs the chart (irrespective of practice ownership). She cannot be a supervising physician as she is not a physician. In that sense we function at a similar level(as stated above), in spite of her independent practice. As a practice owner she is concerned with the viability of the practice and certainly chart review is reasonable. The question was proposed is whether she should be cosigned the charts.

 

as earlier recommended I would recommend against any formal cosigning of the chart for reasons previously stated, the biggest of which is it simply makes no sense. She can do case review without actually signing the chart for quality assurance, which I agree with as it is her practice, with an inexperienced (in female health) provider.