Surgical Attending vs. Medical Consult - and the Query goes too...?

nbrunson84

I work an Orthopedic Surgery floor. Often my Ortho Surgeons will admit and Consult a Hospitalist or Internist for Medical Eval. The reason is that often our Surgeons are not the best at documenting the comorbidities of their patients.

As a practice, I have always directed my Queries to the Attending Physician - he has ultimate responsibility of the patient's medical care.

However, when the attending is a surgeon they are often reluctant to answer the Queries - opting out for the Medical Consult to answer questions regarding medical care.

Often it results in "no one" answering the Query - because the "other guy" should do it.

Any advice on how to handle these situations? I have tried explaining to the Surg/Attending they have ultimate responsibility. Other than have medical admit and Surg. do the Consult...?

Thank you in advance,

N. Brunson, RHIA
Clinical Documentation Specialist
Bay Medical Center

robert.hodges2

I would request clarification from the person who wrote the note. For the consultation, as long as the attending does not contradict it and supports the findings and plan of care, can't that be coded? I would probably only ask that the surgeon refer to the consult response in their notes.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
 
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 
"To climb a steep hill requires a slow pace at first."  -William Shakespeare
 

tiffany_susan

We have adopted the policy of querying the most appropriate physician,
this is not always the attending.

Thank you,
Susan Tiffany RN, CDS
Supervisor
Clinical Documentation Program

dallend@einstein.edu

We have met with our surgeons numerous times regarding this issue with little success. Surgery actually wanted us to have forms that were different colors so they would not have to answer questions.
At this time, we just leave the query on the chart - we direct to "Patient Care Provider" - we give credit to the physician/PA who answers. If the consultant answers and the attending does not contradict the information - it's coded. We have never had a contradiction because surgery only documents as little as possible and there is rarely anything but a princ. diagnosis in their note (if you are lucky). Our surgical PA's are great and our residents are getting better.

cbarnes

We give credit to the provider than answers the query. Oftentimes our surgeons will use a hospitalist as a consultant and he usually answers our queries. Our surgeons are @ best hit or miss with responses. I think most of them resent our role.

kfrosch1

Is your PA's documentation accepted for coding without a co-signature or
acknowledgement by his/her attending?

cbarnes

The hospitalist has to cosign all the PA's notes.

kfrosch1

Even the surgical PA's notes?

cbarnes

There's only 1 hospitalist and he is Internal Medicine and the PA is his associate. That's all we have. No such animal @ our facility as a Surgical PA but we would love to have one !!!!!

nbrunson84

We give credit to the physician who answers the query. All
documentation by PA's must be co-signed by the physician.



N.Brunson, RHIA

Clinical Documentation Specialist

Bay Medical Center

kfrosch1

How does everyone handle Nurse Practioner documentation?

nbrunson84

Same as PA's @ our hosptital.



N. Brunson, RHIA

Clinical Documentation Specialist

Bay Medical Center

cbarnes

We don't have any that round for physicians anymore. When we did have one all her notes had to be cosigned by the physician she worked with.

robert.hodges2

Check your state laws. In Michigan all PA notes require a co-signature.
NP notes do not require a co-signature.



Robert



"To climb a steep hill requires a slow pace at first." -William
Shakespeare

dallend@einstein.edu

We can code from NP and PA notes.