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CAPC Palliative Care Discussion Forum
Leadership and Team Dynamics

Next Reply: Re:RN Documentation/MD Documentation
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Post RN Documentation/MD Documentation
Author: raquelrey
Date: Apr 19, 2011 9:48 am
I am the RN on our Palliative Care Team and will often consult independently from our MD. Most of the time the MD follows-up on consults I have done. One of our MDs uses my notes, addends them and for all practical purposes makes the note his own. He may change or add to the assessment as well as post recommendations and changes to POC. It truly expedites the process especially when we are swamped. We really cannot find anything regarding whether this is allowable or not. He is not just co-signing the note as they would with an NP but mearely using information I have gathered previously. Does anyone have any feedback on this? I would greatly appreciate it.
Raquel Rey, RN, BSN
Director of Palliative Care, Hospice of Alamance-Caswell
Replies: order by [Date] [Author] [Subject]
+ Re:RN Documentation/MD Documentation (by SharolHerr on 04/21/2011)
It is important that all physician documentation and practice meet the medical staff by-laws for your institution. Documentation should include all componenets of a complete assessment, including history and physical, impression and plan, etc. This will also need to be presented in the format that is outlined in the by-laws. Certainly using the information you gathered can be helpful but the notes need to be specifically formatted to reflect the physician expertise. The documentation also needs to include specific components to meet billing requirements for medicare and other third party payers. Here is an outline of the Consult Template that our system uses to meet those medicare guidelines:

Palliative Medicine Consult Template
--Date of Consultation
--Reason for Consultation
--Impression
--Assessment of Symptoms
--History of Present Illness
--Past Medical History
--Past Surgical History
--Current Medications
--Allergies
--Social History
--Family History
--Advanced Directives
--Review of Systems
--Physical Exam
--Diagnostic Studies
--Old Records
--Case Discussion
--Other
o Patient/Family Understanding
o Goals of Care
o Psychosocial Review
o Spiritual Assessment
o Life Closure Tasks
o Ethical Considerations

Sharol Herr, RN, BSN, MSEd; Clinical Manager Palliative Care Services; Mount Carmel Health Palliative Care Leadership Center; Columbus, Ohio.

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