A number of months ago, I wrote an article for RACMonitor.com about medical staff rules getting in the way of appropriate patient status
. I pointed out that some hospitals have medical staff rules which state discharge summaries aren't required for patients in Outpatient status WITHOUT Observation services. With a rule like that in place, ensuring surgeons place an appropriate order for Observation services when post-operative recovery becomes complicated can be challenging.
Since then, I have learned that this is not an uncommon practice. Op notes are challenging enough to create within 24 hours of a procedure, adding a discharge summary into the mix is sometimes just too much to bear. But, why? Why does it have to be this way? If a complication was simple, simple but enough to warrant an Observation services order, why can't completion of a discharge summary be just as simple? Documenting that a specific procedure was done, that the patient experienced more nausea and vomiting post-op than is normally expected, and required IVF and a few doses of IV Zoran overnight until they proved they were able to tolerate PO intake the following morning, should not require the creation of a tome.
But, it seems this is the mindset of some physicians. Is is justified? Perhaps, perhaps not. I think a lot has to do with the manner in which discharge summaries are created within the electronic health record. Are templates available which are nimble and pre-populate necessary information entered elsewhere in the record? Or, does each document need to be created from scratch? Could it be there are templates available, but they are so cumbersome no one wants to mess with them?
Even with well-designed templates in place, the urge by physicians to fight completing one more piece of documentation can be strong. As Physician Advisors, we not only discover opportunities and fall-outs, but come up with manners in which they can be addressed. Take some time to really dig into why your surgeons want to avoid creating discharge summaries. Is your electronic health record working as a tool for the physicians, or serving as dead weight? If you have terrific templates which have been updated recently and work like a charm, do all of your physicians know about them? Or, do they know about them, but were never taught how to implement them?
As with other elements of appropriate status, it is important to rely on case managers and even bedside nurses to assist in determination. Make sure they know what kinds of situations warrant an order for Observation services in the post-op period and that they ask for the order when it's appropriate. Also, make sure they notify you if a physician refuses to place the order. Every refusal should be investigated. Did the case manager or nurse judge something incorrectly as a recovery complication? Did the physician think a specific amount of time had to pass before the order was justified? Or, is it the hesitancy of creating that discharge summary? If the latter, make it clear that avoiding placing a patient into "Observation status" to avoid additional documentation is not acceptable. Make sure your VPMA is aware, and consider performing intermittent reviews of the physician's cases to ensure further instances do not occur.
If you've found a way to effectively monitor and address this challenge, please comment below! Also, have any facilities made discharge summaries mandatory for ALL patients, even those bedded Outpatients without recovery complications? If so, I'd love to know!