Musical Attending Providers

cmorellcmorell
in CDI Talk Archive
This scenario is often seen when you have a group such as hospitalists who continually transfer care to each other.

1. Who is the "captain of the ship" when you have conflicting documentation among providers in the same practice?

Last person to dictate? The discharge summary?
My thought is without an official "change service to another provider order" it would be the attending when the patient was admitted.

2. But what if you have a "change patient to Dr. X's service" irder (say Intensivist in the ICU) and then another change order when the patient goes to the floor. It is the last attending the captain? Again, this is in the case of conflicting documentation.

Scenario for reference: Pt admitted to floor then goes into the unit with Sepsis, has end stage renal disease, the hospitalist documents Severe Sepsis but the Intensivist disagrees because the renal failure is NOT related to the Sepsis. So the Intensivist documents Sepsis NOT Severe Sepsis.

The Intensivists are wondering about trying to have policies saying they are the attending in the unit.

I think their policies don't matter, CMS policies matter. Unless they stay attending and have the hospitalist just be a consult. But, that record could still have 2 attending physicians, one early in the admission prior to the transfer to ICU. So, again, with 2 Attending Physicians on record who gets the final say?

Any citations for reference would be appreciated :) Thanks!

Charlie Morell

Comments

  • lprescottlprescott
    Charlie, we have that problem with our hospitalists. They work 7 days on and 7 days off. We follow the rule whomever writes the discharge summary has final rule. And yes the query rate for these guys is high due to conflicting documentation.

    I would suggest if they have scheduled business meetings you get on the agenda to speak to this specific issue. Use examples of the contradictions. I tired to get to their monthly meetings 3-4 times a year.

    suggestions given to minimize the contradictions and clarification needs include-
    1. Write every note with a thorough list of diagnoses- those still in treatment, those that have resolved, chronic issues being watched.
    2. When a new diagnosis is added to the list- define if POA or developed after.
    3. Always read the H&P and Progress notes of previous provider on the case. If you disagree with identified diagnoses and treatment plan- clearly state your new diagnoses and rational for the change. Otherwise if you agree, continue using the same terms.
    4. When discharge time arrives- review the H&P again. If the progress notes are thoroughly written each day the last progress note should reflect the diagnoses for the entire stay and evolution of the treatment plan.
    5. for EVERY diagnoses on your discharge summary clarify if present on admit or developed after.

    discussing these items has improved the situation. They also try to assure on there last day on that their progress notes are the most thorough and of highest quality. sometimes it works - sometimes not.

    As for when you have an intensivist covering- the attending always has the final rule.

    Hope this helps...and know you are not alone!
    Laurie Prescott RN, MSN, CCDS, CDIP
    Lprescott@morehead.org
  • sharon.colesharon.cole
    edited May 2016
    Unfortunately for us, it's whoever writes the DC summary. I recently had a record that the pulmonologists throughout the chart documented Aspiration PNA. The hospitalist who was the attending continued to only document HCAP (before and after he consulted pulmonology) - including the DC summary. So it coded to PNA NOS. Coding told me it was conflicting documentation and that's why they went with 486.

    Sharon Cole, RN, CCDS
    CDI Specialist
    254.751.4256
    Sharon.cole@phn-waco.org

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Does your facility have an attribution policy for coding? We (the hospital, not CDI) designed a new one 2 years ago. Ours is much more complex than many other facilities. With the increasing scrutiny on providers regarding quality measure and such, there was a lot of but in to 'get it right'. There are still times where it doesn’t seem to be an accurate reflection but I think it’s the best we can do. When I do post-discharge reviews/queries, I follow the attribution policy for the most part.
    Concurrently, we also have constantly changing attending. Most our providers are treated by hospitalists or intensivists. We query whomever is caring for the patient that day (for the most part).
    In the situation you reference, my gut response would be to go with the intensivists. Cases are evolving. I would not go with the admitting providers documentation days prior over the provider caring for the patient currently. That is from a clinical standpoint at least. From a coding standpoint, I think it would depend on an attribution policy and a query may be in order.


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Ok. Ignore all my typos. It's way too early and I have not had my coffee :)

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • dvitalone1dvitalone1
    edited May 2016
    In this case a query should have been sent due to conflicting documentation and not just by what DC summary stated.

    Dawn

  • stein.patriciastein.patricia
    edited May 2016
    When confronted w/ a situation like this, a write a query for "conflicting information in the medical record". I quote directly from the sources and leave it to the docs to decide. This has been effective for me. I think a policy would sincerely tangle you in knots and hamper care, leaving the pt hanging.
    Hope this helps.


    Patricia Stein
    Clinical Documentation Specialist
    Scripps Green
    760-274-7397 (cell)
    858-554-4709 (office)

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Prior to our attribution policy, ours was whomever wrote the d/c summery as well. Seems like a retro query should have been sent in this case. I understand that it is a 'conflict' but we should query for such conflicts.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • lprescottlprescott
    I agree katy a query should be placed onthe retro side if not resolved concurrently. This is what is motivating our hospitalists to creat consistentcy or explain inconsistencies while completing initial documentation. Retro queries take way more time from their day.

    Also as CDSs, we do try to concentrate on these charts and on the day of the switch of attendings we try to be available and focus on their charts more so than normal.

    Laurie Prescott
  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    Patricia,
    We do the same thing at our facility. We just address the query to the Primary Team, note that the diagnosis must be consistently documented across all providers and to ensure that they document the diagnosis in the discharge summary.
    This has been successful for us also.


    Deborah A Dallen,RN, CCDS
    Albert Einstein Medical Center
    Phila PA 19141
    Clinical Documentation Coordinator
    Health Information Management
    215-456-8902


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