Physician encounters should be long-term relationships, not one-night stands
Excellent read (link at conclusion of blog) about the misconceptions of Emergency Department care as primary episodic care, significant inroads are being made to integrate ED care with primary care. The key take away point for me in the article is the following:
Better communication naturally ties into better collaboration. Every visit, diagnosis, allergy, prescription and more has the potential to radically change how a physician interacts with a patient.
In my continued quest to provide feedback to physicians on best strategies for enhanced communication of patient care focusing upon medical necessity denials, I notice a common theme, ineffective communication within the record, particularly when consultants are on board. There appears to be little collaboration between physicians on the case attributable to insufficient communication. The attending is not driving the ship, tying all the clinical information, facts and context together in a concise, consistent, clear and contextually correct patient story with the ability of the reader to find the patient within the story. As a result, each progress note does not lend itself to supporting and describing, showing, telling, depicting and reflecting a clear patient story. Progress notes don’t clearly and accurately reflect the clinical progress of the patient, it is hard to identify and determine whether the patient is clinically getting better, staying about the same, or worsening. When you read the physician orders, the reader attains a better understanding of how the patient is faring, distinctly different from the progress note which is devoid of any or little documentation summarizing clinical changes and the initiation of plan of care changes. It is simply not enough for the CDI specialists to clarify a diagnosis and equate this to documentation improvement and integrity. An accurate and complete telling of the patient story entails recording a clearly updated interval history that includes any clinical changes that manifested from the time of the last visit the previous day, any new complaints or issues as stated by the patient, what is wrong with the patient, how does the patient look and how did it manifest. This interval history is instrumental in updating the patient story, painting a clear snapshot picture that accompanies and supports the physical exam and clinical impression with plan of care. The patient story as recorded must flow logically and be easily read and understood by all physicians and other healthcare stakeholders participating in the care of the patient including case management and utilization review staff who are totally dependent upon the quality and completeness of the communication of patient care to execute their roles and duties for the patient and physician. Indisputably, effective communication of patient care facilitates effective collaboration supporting ideal outcomes and the optimal integrity of the revenue cycle.
Achieving Communication with Collaboration
Achieving communication of patient care that facilitates and fo