Disagreeing attending physicians

Unknown

I was wondering if anyone has experience or could give me some recommendations on conflicts in documentation between two attending hospitalists. We have been running into situations where the patient is admitted and cared for by one physician for one or more days then when the hospitalists change, the new physician states that the diagnoses for which the patient has been treated are false. This second physician dictates the discharge summary and does not include the same diagnoses. I have asked him to include at least what the patient was treated for which he adds but prefices these diagnoses with statements of these diagnoses not being present.

Ex: A recent patient was admitted with acute resp failure secondary to acute diastolic CHF and pneumonia. There was documentation of PO 89% on RA, RR 32, WBC 17.3, CXR from physician's office showed infiltrates. Also found was an H/H 5.5/17.2. Pt also has hx of myelofibrosis and CKD stage 3. Pt received IV Atb's, IV lasix, PRBC, O2, aer. The discharging physician lists "symptomatic anemia," "myelodysplastic syndrome" and "ischemic cardiomyopathy" as the discharge diagnoses. He states that the pt was treated for pneumonia and CHF but these were "unsubstantiated in the medical record."

Any thoughts?

Thank you,
Lisa Taylor,RN
Wooster Community Hospital

mannb1

Do you have a CDS physician champion/medical director who could review the case & give their input, and possibly speak w/the discharging hospitalist? Or is there a "lead" hospitalist, who you could ask to review the chart, or give advice as to how to approach the dissenting MD?

dog

Wow, I think you have a bigger problem than what to code. A physician who disparages another physician within the medical record (such as calling their diagnoses "unsubstantiated") is really a bomb waiting to go off. Not only should the physician advisor look at those charts, but so should the medical director and risk management. An attorney with that chart in their hands would have a field day.

Renee

dallend@einstein.edu

We do no have a physician champion. We refer cases such as these to our Chairman of the Dept of Medicine. This is definitely an MD to MD issue. I have forwarded several charts to our Chairs of Medicine and Surgery. They will usually review the chart first then contact the MDs who were involved in the case.

gail_marini

Couple of suggestions.
We have a custom query which outlines ... "In the H+P or in the note
________ Dr. ________ documented the following diagnoses.
(blah,blah,blah).
In an effort to provide continuity of diagnoses throughout the record,
please document in your note today whether this diagnosis :
*still being treated
*improving
*resolved
*ruled out
*other
Please feel free to page me ... (blah, blah, blah)
Second opportunity - sit with a couple of these charts with whoever in
your facility is in charge of the hospitalists. We certainly don't want
to over diagnosis and it is "after careful study" but the importance of
continuity in the chart is essential.

Gail Marini MM, RN, CCS
Manager Clinical Documentation (CDI)
Finance Department
781-624-8413 B-7757

cbarnes

I think Renee's response says it all. Charlene #2

Unknown

I agree. Renee says it all.
Gail your query is great!

Gina Spatafore, RN
Clinical Documentation Integrity Specialist
Waterbury Hospital
203 573 7647

robert.hodges2

I'm with everyone else. This is a problem, but I have the same thing
here since we are 100% hospitalists. What we do then is query the
discharging hospitalist much as Gail says but if we don't get a timely
response, we ask the chief hospitalist to review the record to ensure it
is complete and accurate. It's not something I normally get involved in
since it is a retrospective query and those are done by coding here.



If you have a physician champion, have them review it and then get
involved. It's like doing UR and doing a physician advisor review.
Doc's do better talking to doc's.



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



"Anyone who has never made a mistake has never tried anything new."
-Albert Einstein

Unknown

Thank you for all of your recommendations!



We do not have a physician champion but do have a co-directors for our
hospitalists. I will present some of these charts to them and see if
they can get anywhere with this particular physician. His documentation
overall is the most challenging.



Should I not ask him to include the other diagnoses that were charted by
the other physicians since he adds the commentary with them?



Thank you,

Lisa Taylor, RN

CDIS

Wooster Community Hospital

robert.hodges2

Lisa,



Rather than asking him to add them, perhaps asking him to address them
with a resolution to those issues they disagree with.



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



"Anyone who has never made a mistake has never tried anything new."
-Albert Einstein

dog

Gail, I like your query form. How close to discharge can your patient be when you use that form and still have the diagnoses count?

Renee

Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital

gail_marini

As long as the diagnosis is supported in the medical record as the pdx -
the discharge summary is the final clarification.

Gail Marini MM, RN, CCS
Manager Clinical Documentation (CDI)
Finance Department
781-624-8413 B-7757

dog

Gail,

I just used your query form to get a physician to make a decision about a diagnosis that was documented as "possible." Love it!

Renee

Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital

Unknown

Gail,

I could not find the e-mail where you sent this out, could you please resend?