Procedure consent

[bedrock]

One of our surgeons is giving me a hard time because I don't personally visit with patients and personally write out the consent for each of my patients on procedure days. This is how I handle it for patients I've personally seen in the past month. If seen more than a month ago, I do briefly visit with them to ensure the patient and I are on the same page. I think he is off base because I see 90% of my patients in clinic within two weeks prior to their procedure.

Please be honest. I hope to give him real data about practical pain medicine.

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[MitchLevi]

I don't leave the procedure room.

 

[lobelsteve]

Done by nurses day of procedure after they check in. Time Out done in room.

 

[Ducttape]

procedure discussed in office visit prior. can be days - even months - prior. ie trigger point injection.

ASC "requires" some sort of physical within 30 days of procedure.

regardless, i sign with patient in moments before procedure.

 

[lobelsteve]

At hospital or in office, the patient and a witness (RN/LPN) sign. No place for me to sign.

 

[pastafan]

Informed consent is a process. The consent form is a means to document the process. Obtaining informed consent, the process, cannot be delegated to a nurse. The discussion should be documented in the physician's notes.

CMS has requirements for timing of H&P. While it need not be performed on the day of the procedure, the physician must document that there has been no change in the patient's condition since the H&P was performed.

https://www.magmutual.com/learning/article/informed-consent/

 

[DrMDAware]

Informed consent is a process. The consent form is a means to document the process. Obtaining informed consent, the process, cannot be delegated to a nurse. The discussion should be documented in the physician's notes.

CMS has requirements for timing of H&P. While it need not be performed on the day of the procedure, the physician must document that there has been no change in the patient's condition since the H&P was performed.

https://www.magmutual.com/learning/article/informed-consent/

No mad at you. But CMS isn’t the end of be all. I know guys who are out of network or not Medicare accredited killing it. CMS wants us to jump through all these hoops and they keep cutting our reimbursement.

Ok so when the patient wants to talk about a new condition, some imaging or something else on the day of injection I theoretically can bill for a separate note -25. That’s a waste a time and doesn’t really pay. I’m paying the DON, HVAC, equipment etc in the ASC to be there for one thing - to do procedures!

Have a question about doing PT after? It’s on the post op instructions.

Now sure when to take the Bandaide off? Why am I paying a nurse then?

/rant

 

[willabeast]

Always consider how things will look at a deposition. Not everyone has an intact memory or IQ over 100. Never had to face a jury, but I imagine every little bit helps. Think about it - you have an IQ of 70. You are seeing multiple specialists. You are taking all sorts of medication your FP gave you. You wake up one day way worse than before you saw the pain doc, surgeon, FP, PA, PT. Maybe you got confused which consent covered what. We all have high IQs. Not a mistake we would make but I imagine most of us would have paid more attention. Add in that there are some people who will lie during a depo (believe me I have seen it). Get that consent in person just before the procedure. My two cents.

 

[pastafan]

No mad at you. But CMS isn’t the end of be all. I know guys who are out of network or not Medicare accredited killing it. CMS wants us to jump through all these hoops and they keep cutting our reimbursement.

Ok so when the patient wants to talk about a new condition, some imaging or something else on the day of injection I theoretically can bill for a separate note -25. That’s a waste a time and doesn’t really pay. I’m paying the DON, HVAC, equipment etc in the ASC to be there for one thing - to do procedures!

Have a question about doing PT after? It’s on the post op instructions.

Now sure when to take the Bandaide off? Why am I paying a nurse then?

/rant

I understand your frustration. Having been chief of staff in a former life and going through multiple JCHAO inspections, I get it. That is why I always advocate avoiding JCAHO accreditation and going with DNV GL-Healthcare (DNV GL) instead. Totally different philosophy and process.

https://www.ormanager.com/wp-content/uploads/2015/06/0715_ORM_01_Regulations.pdf

 

[bedrock]

Thanks for input so far. Everyone please make your votes.

Right now it’s 50/50 each way

 

[Agast]

I don’t write the consent but I have to sign it. I talk to the patient in Preop to reiterate what we are doing or our Press Ganey scores will go into the toilet. Not sure that fits with the poll options.

 

[SSdoc33]

Just sign only.

 

[callmeanesthesia]

I don't leave the procedure room.

Same. Preop MA has patient intial and sign consent form. I sign it when they come to the room. Before the patient gets on the table, I talk to them, and if it’s my first time meeting them I confirm key details of history and often do a brief PE. I explain the procedure to them and answer any questions they have.

 

[Agast]

Before the patient gets on the table, I talk to them, and if it’s my first time meeting them I confirm key details of history and often do a brief PE. I explain the procedure to them and answer any questions they have.

How is it your first time meeting them?

 

[Taus]

I have to see all briefly and sign consent in pre-op area.

 

[callmeanesthesia]

How is it your first time meeting them?

I have mid-levels who see new patients. I also take direct procedure referrals from some of the local spine surgeons.

 

[knoxdoc]

I have to see every patient and sign consent prior to going back to the procedure room as well (ASC). I spend about 30sec - 2 min doing so. For routine repeats, its "ok you know the drill, any questions for me today?" If no, off we go. It doesn't slow me down and I know that we are all on the same page.

 

[DrMDAware]

Of course I’d like to highlight the fact how many procedures are done and how someone is paid (RVU, salary, ownership in facility) play a factor into the approach to meeting the patient beforehand.

A colleague of mine routinely does 8 bread and butter injections in about 5 hours. He is salaried. He pays no overhead in a direct sense to his knowledge.

Needless to say he sees absolutely no problem marking every patient and chatting with them.

So perhaps the data will reflect who is salaried vs who is not etc.

 

[kstarm]

Similar to Knoxdoc: Hospital based, required to do face-to-face consent for our procedures and done the day of the procedure. I have caught enough errors to know doing this every time works well for me. Takes about 1-2 min.

 

[clubdeac]

I understand that surgeries require a “pre-op H&P” but an injection? That’s insane. Where does it say you need one? Do you do an H&P for trigger points? Fluoro joint injections? Bursa injection? GON block? If not then why not? You probably should to be consistent

Personally I think that’s excessively superfluous and redundant and the biggest waste of time ever. No one even does a real H&P when they do pre-op H&Ps so what’s the point

 

[cowboydoc]

I have mid-levels who see new patients. I also take direct procedure referrals from some of the local spine surgeons.

Thread derailment in 3…2…1…

 

[Ferrismonk]

I understand that surgeries require a “pre-op H&P” but an injection? That’s insane. Where does it say you need one? Do you do an H&P for trigger points? Fluoro joint injections? Bursa injection? GON block? If not then why not? You probably should to be consistent

Personally I think that’s excessively superfluous and redundant and the biggest waste of time ever. No one even does a real H&P when they do pre-op H&Ps so what’s the point

Pre-op H&P is a medicare requirement for ASC/OR. If done in the office, not needed.

So yes, if you do a trigger point boarded in an ASC, you need to do an H&P too.

 

[clubdeac]

Pre-op H&P is a medicare requirement for ASC/OR. If done in the office, not needed.

So yes, if you do a trigger point boarded in an ASC, you need to do an H&P too.

Medicare sucks

 

[oneforfighting]

Not sure how to answer the poll so I’ll answer here. For reference, I do all my injections at the hospital. I try to consent all patients in clinic. If within 30 days, I will see the patient and mark them, answer any questions, and then we will bring them back for the procedure. If outside of 30 days, we are required to redo a consent. I don’t really redo an exam, unless something has drastically changed in the interim. For kyphos, I will listen to heart and lungs and do a lower extremity strength exam.

 

[Welcome123]

No mad at you. But CMS isn’t the end of be all. I know guys who are out of network or not Medicare accredited killing it. CMS wants us to jump through all these hoops and they keep cutting our reimbursement.

Ok so when the patient wants to talk about a new condition, some imaging or something else on the day of injection I theoretically can bill for a separate note -25. That’s a waste a time and doesn’t really pay. I’m paying the DON, HVAC, equipment etc in the ASC to be there for one thing - to do procedures!

Have a question about doing PT after? It’s on the post op instructions.

Now sure when to take the Bandaide off? Why am I paying a nurse then?

/rant

CMS is a standard that can be used against you in case any attorney wants to point out what you should have done. It is also an excuse insurance can use to deny payment. It may not make sense and in fact many times does not.

 

[Welcome123]

I understand that surgeries require a “pre-op H&P” but an injection? That’s insane. Where does it say you need one? Do you do an H&P for trigger points? Fluoro joint injections? Bursa injection? GON block? If not then why not? You probably should to be consistent

Personally I think that’s excessively superfluous and redundant and the biggest waste of time ever. No one even does a real H&P when they do pre-op H&Ps so what’s the point

The point is learning how to “dance”

 

[Ducttape]

Medicare sucks

in terms of medical care, i would argue that an H&P - or at least a meet and greet - is mandatory. it helps establish a doctor-patient relationship. it helps provide reassurance to the patient and may help them feel more comfortable about the skills of the interventionalist.


an injection is still a procedure. it is not like a physical exam or counselling. there are risks above and beyond the usual office visit. you may think that there is minimal risk of an infection, but if the patient gets one and was unaware that that was a possibility - thats when they get upset, even sue. i consent for every injection, even toradol shots (not written consent for this)


those risks need to be present to the patient. as important to me, reasonable expectations need to be presented.

 

[clubdeac]

in terms of medical care, i would argue that an H&P - or at least a meet and greet - is mandatory. it helps establish a doctor-patient relationship. it helps provide reassurance to the patient and may help them feel more comfortable about the skills of the interventionalist.


an injection is still a procedure. it is not like a physical exam or counselling. there are risks above and beyond the usual office visit. you may think that there is minimal risk of an infection, but if the patient gets one and was unaware that that was a possibility - thats when they get upset, even sue. i consent for every injection, even toradol shots (not written consent for this)


those risks need to be present to the patient. as important to me, reasonable expectations need to be presented.

yes I agree and that is why I try to see all of my injection patients for a consult before the injection. Sometimes I take direct referrals from the surgeons but this is not ideal. So yes, I'm talking about an H&P the day of the injection after the patient has already been seen in the office. This appears to be nothing more than extra paperwork for the sake of checking off a medicare box

 

[Ducttape]

yes I agree and that is why I try to see all of my injection patients for a consult before the injection. Sometimes I take direct referrals from the surgeons but this is not ideal. So yes, I'm talking about an H&P the day of the injection after the patient has already been seen in the office. This appears to be nothing more than extra paperwork for the sake of checking off a medicare box

you might be surprised to learn that many interventionalists do not see the patient before their procedure, or even bother talking to them, let alone an H&P.

or maybe not surprised... it is much faster and lucrative to just be a needle jockey and nothing else.