Bro sign outs ?

[Groove]

It is rare to sign out such a thing. If I am that busy in the last hour of my shift, I probably won't see the patient and start anything anway as I will be too busy trying to disposition as many of the completed patients as I can. They will be a "new" patient for the oncoming.

LOL, really? I'm sorry man but there's just never a good reason to sign out a pelvic exam to an oncoming doc. "I can't do the pelvic because I won't leave on time" just doesn't cut it. It's inappropriate, poor form and you know it. I recall you mentioning you had the lowest RVU/pt in any group you had practiced in over in the EMCare thread. Ever stop to think that a few more lac repairs and pelvic exams might change that?

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[BoardingDoc]

Luckily I'm in an RVU model. I love the sign outs. Give them all to me. I get up immediately and start over with all of them but I document "transition of care" on every single one and they all go towards my productivity. The only ones that are annoying are the pelvic sign outs. I've got this night doc that has signed out two to me in the last month. I even asked him point blank "Dude...you're not signing out a pelvic to me are you?" "Noway man, no GU complaints at all". Yeah right...

And for the love of God please don't save a 2 hour lac repair until the end of your shift and then try to sign that out to me. Not happenin....

I assume that everyone in your group does this? If not and you're the only one writing a new chart for signouts and effectively stealing their RVUs, that's pretty shady.

 

[Groove]

I assume that everyone in your group does this? If not and you're the only one writing a new chart for signouts and effectively stealing their RVUs, that's pretty shady.

So, if you sign out your patients at shift change to an oncoming doc to further manage and disposition, how exactly is that not a transition of care? If I have to get up and examine your patient, document that exam, finish your work up and/or make a disposition decision on management, why on earth should you get credit for my work when you are no longer physically in the department to take care of the pt? I would consider it shady if someone is routinely signing a chart 2 hours after another doc has finished the work up and dispositioned them and claiming credit for the entirety of that pt encounter. That's fraudulent and a liability risk. Personally, I wouldn't even want to sign a chart on a pt where I handed care over to another physician. I'm just as anal about documenting transition of care when I sign pt's out as I am when I pick them up.

 

[WilcoWorld]

My RVU-based bonus is something like 5% of my pay, so I don't really have a dog in this fight. But I think the doc who dispositions the patient should get the RVU's. If you're discharging the patient, you're taking the liability risk, so you should get the RVUs. If you want the RVU's, simply discharge the patient before you leave.

 

[GeneralVeers]

LOL, really? I'm sorry man but there's just never a good reason to sign out a pelvic exam to an oncoming doc. "I can't do the pelvic because I won't leave on time" just doesn't cut it. It's inappropriate, poor form and you know it. I recall you mentioning you had the lowest RVU/pt in any group you had practiced in over in the EMCare thread. Ever stop to think that a few more lac repairs and pelvic exams might change that?

Not what I said. I stated if I am busy I don't pick up or see new patients during the last 30 minutes of my shift unless they are critical. Remember, I am single coverage with no overlap. I spend my last 30 minutes dispoing all the patients I have already seen and worked up. That actually helps my RVUs, whereas seeing a patient, doing an extensive exam and signing out actually hurts my RVUs as I get no credit. The others in my group (very low morale) actually stop seeing patients in the last 1-2 hours of their shifts so I don't feel bad.

 

[BoardingDoc]

So, if you sign out your patients at shift change to an oncoming doc to further manage and disposition, how exactly is that not a transition of care? If I have to get up and examine your patient, document that exam, finish your work up and/or make a disposition decision on management, why on earth should you get credit for my work when you are no longer physically in the department to take care of the pt? I would consider it shady if someone is routinely signing a chart 2 hours after another doc has finished the work up and dispositioned them and claiming credit for the entirety of that pt encounter. That's fraudulent and a liability risk. Personally, I wouldn't even want to sign a chart on a pt where I handed care over to another physician. I'm just as anal about documenting transition of care when I sign pt's out as I am when I pick them up.

So you're saying everyone else does this then? I'm not questioning your logic, I'm questioning if this is what everyone in your group does. In my group, if I get a "dispo per CT signout" and it turns out that they have actual pathology which I treat and admit, but nothing else changes, I don't chart on them. I just do that little extra bit of work. If the patient is "going home after the UA comes back" and then has an MI in the dept, I write a chart. Obviously there's some wiggle room in the middle, but the vast majority don't get a new chart. I'm not saying my culture is better or worse, it just is what it is. If in your group, everyone routinely starts new charts for most signouts, great. If not, that brings me back to my initial statement.

 

[BoardingDoc]

My RVU-based bonus is something like 5% of my pay, so I don't really have a dog in this fight. But I think the doc who dispositions the patient should get the RVU's. If you're discharging the patient, you're taking the liability risk, so you should get the RVUs. If you want the RVU's, simply discharge the patient before you leave.

Totally agree that this is a valid way to do it and honestly, it's probably simpler than the alternative. That said, it should be pretty clear cut if this is how your group does it or not. If so, problem solved. Everyone just charts on signouts. Easy. On the other hand, if your group has a general group policy that whoever does the bulk of the work gets the bill (generally the 1st doc), and then one person routinely opens a new chart on all signouts to claim the RVUs, it feels like theft.

 

[Groove]

So you're saying everyone else does this then? I'm not questioning your logic, I'm questioning if this is what everyone in your group does. In my group, if I get a "dispo per CT signout" and it turns out that they have actual pathology which I treat and admit, but nothing else changes, I don't chart on them. I just do that little extra bit of work. If the patient is "going home after the UA comes back" and then has an MI in the dept, I write a chart. Obviously there's some wiggle room in the middle, but the vast majority don't get a new chart. I'm not saying my culture is better or worse, it just is what it is. If in your group, everyone routinely starts new charts for most signouts, great. If not, that brings me back to my initial statement.

I'd be very careful continuing that pattern in your current environment. Who's taking care of that pt when your colleague "signs them out" to you and physically walks out of the dept? If he/she hasn't discharged or admitted them...then you are. If something bad happens to that pt or something gets missed, you're the one that's going to get burned, not him. Actually, you both probably would get burned but you def wouldn't be off the hook simply because you didn't chart on them. That doesn't protect you at all. He's simply going to testify that he handed over care of the pt to you at shift change to continue management and f/u existing studies. You're going to have to testify under oath that a "transition of care" discussion did occur and you're going to have a helluva time defending why you thought the doc who just left the building was still managing the pt. A lawyer is going to have a field day asking you why you didn't get up and examine the pt and if you did examine them he'll continue to have a field day asking why, if you examined them after a transition of care discussion, did you not expect to assume care of the pt? Landmines everywhere my friend. These are exactly the types of pt's where mistakes happen and sh** gets missed. It's not worth stepping on toes or hurting someone's feelings because they didn't get to file for those RVUs. If I get a clear sign out from a doc, I get up, examine them and most of the time start over. I take over the chart and clearly document that care was handed over to me at X:XX. I get no argument from any of my colleagues and yes that is our standard practice.

I think these types of pt's should have very clear transitions of care and I like clear expectations from the doc signing out on what I'm supposed to do with the pt. Like mentioned above, if you are the physician who ultimately makes a decision to admit or discharge, then the liability is on you and you should get the RVUs for that encounter. What's not fair about that?

Sure, there are times when I will make some exceptions but by and large those are pt's still in the dept where the doc has discharged them already and they are either waiting for a ride or waiting for a BAL to get to a certain point or he's just letting me know about them on the small chance that something happens while they are waiting for a bed upstairs and what have you, etc..

However, if you're admitting or discharging your partner's pt's after they leave and something happens to them, you're going to get named in that lawsuit my friend. Lack of documentation in those cases is going to hurt you, not help you.

 

[Rendar5]

At my shop it's a little more even. Any sign-outs, both providers split the RVU's for the basic code level. Procedure RVU's go to the person who did the procedure itself. As long as everyone practices the same though it Should not matter.

 

[Groove]

At my shop it's a little more even. Any sign-outs, both providers split the RVU's for the basic code level. Procedure RVU's go to the person who did the procedure itself. As long as everyone practices the same though it Should not matter.

How do you guys do that? I can see where the procedures get billed for the provider who did them but how are you splitting the RVUs? The coders are going to bill the chart based on the physician who signed it unless there's a documented transition of care. I'm not aware of how a coder would "split a chart" in two and bill the pt based on both providers arbitrary % involvement. So, are you as a group going back and splitting the RVUs between the two docs and withholding money generated on the chart from the billing doc in order to split it based on an arbitrary "RVU split"? I've never heard of that. I'm not sure how that would work very smoothly.

 

[Rendar5]

Chart generates x rvu's. Coders see that two docs signed note and each saw the put. Each doc gets half the rvu's. It's not a really hard calculation. And why wouldn't you document transition of care?

 

[Groove]

Interesting... I'm not a coder but I thought you had to bill the entire encounter (minus sep procedures completed by another doc, etc..) under only one provider.

 

[WilcoWorld]

Interesting... I'm not a coder but I thought you had to bill the the entire encounter (minus sep procedures completed by another doc, etc..) under only one provider.

It does seem complicated, but it doesn't seem impossible, to bill under one provider and pay out to two.

 

[BoardingDoc]

I'd be very careful continuing that pattern in your current environment. Who's taking care of that pt when your colleague "signs them out" to you and physically walks out of the dept? If he/she hasn't discharged or admitted them...then you are. If something bad happens to that pt or something gets missed, you're the one that's going to get burned, not him. Actually, you both probably would get burned but you def wouldn't be off the hook simply because you didn't chart on them. That doesn't protect you at all. He's simply going to testify that he handed over care of the pt to you at shift change to continue management and f/u existing studies. You're going to have to testify under oath that a "transition of care" discussion did occur and you're going to have a helluva time defending why you thought the doc who just left the building was still managing the pt. A lawyer is going to have a field day asking you why you didn't get up and examine the pt and if you did examine them he'll continue to have a field day asking why, if you examined them after a transition of care discussion, did you not expect to assume care of the pt? Landmines everywhere my friend. These are exactly the types of pt's where mistakes happen and sh** gets missed. It's not worth stepping on toes or hurting someone's feelings because they didn't get to file for those RVUs. If I get a clear sign out from a doc, I get up, examine them and most of the time start over. I take over the chart and clearly document that care was handed over to me at X:XX. I get no argument from any of my colleagues and yes that is our standard practice.

I think these types of pt's should have very clear transitions of care and I like clear expectations from the doc signing out on what I'm supposed to do with the pt. Like mentioned above, if you are the physician who ultimately makes a decision to admit or discharge, then the liability is on you and you should get the RVUs for that encounter. What's not fair about that?

Sure, there are times when I will make some exceptions but by and large those are pt's still in the dept where the doc has discharged them already and they are either waiting for a ride or waiting for a BAL to get to a certain point or he's just letting me know about them on the small chance that something happens while they are waiting for a bed upstairs and what have you, etc..

However, if you're admitting or discharging your partner's pt's after they leave and something happens to them, you're going to get named in that lawsuit my friend. Lack of documentation in those cases is going to hurt you, not help you.

Yep. If the general SOP at your place is to take over and do your own thing with the patient, as I said, that makes for a very easy signout system where it works for everyone. I don't happen to have that system, and I completely agree about the inherent risk involved. If the plan is to admit, I get the one liner. If the plan is to discharge, I check to make sure that the plan made sense more thoroughly and that I agree with them going home. If the plan changes in any appreciable way, I write a chart and start over.

I like my system because you can have a patient 98% done and not feel like you need to wait an hour after your shift to go home or else you don't get paid as much. I in no way think yours is a bad one, just a different cup of tea with different risks and benefits.

 

[emergentmd]

I would never signs our a Lac Repair, Chest tube, LP, central line, or anything that will require time. Do what you would want other to do to you.

I would say no to the above sign outs. They can hang around for an hour to do the procedure. If the pt came in 30 min ago and has a big lac, just save it and Ill deal with it. If the pt has been there for 2 hrs then you need to either have done it or do it when I came on.

In 15 yrs, I have NEVER signed out any of the above. I have worked in RVU shops, Locums that is rate only.

If 10 pts showed up in the last hour, I would deal with anything critical and I can admit in an hour or something simple. Everything else that requires a large workup can wait for the next doc.

If I am in a good mood, I would put in orders without seeing the pts.