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Who does your discharge paperwork?

  • PGY-1's/interns

    Votes: 30 88.2%
  • Residents

    Votes: 3 8.8%
  • Attendings

    Votes: 1 2.9%

  • Total voters
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Gfliptastic

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I recently attended a pharm dinner hosted by a (doctor) father of a co-intern's and afterwards he spewed so much disdain for our duties as interns. (He is affiliated with two very good programs). His beef was that we do EVERYTHING related to a discharge. We do the discharge instructions, discharge medication rec, discharge summary. All the attendings do is review, minor edit, sign.

He told us that these should be responsibilities of attendings, since this is a main component to the hospital receiving payment (he said the reimbursement is $150 for just the discharge summary).

A discharge usually takes up 30 minutes, but on a busy service you can end up w/ 3-4/day. (I did 17 in a 3 day span once). He told us this is time we should be learning/reading. This is unnecessary SCUT work for us. But this is the way it has always been at our program.
 

marsh20

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I recently attended a pharm dinner hosted by a (doctor) father of a co-intern's and afterwards he spewed so much disdain for our duties as interns. (He is affiliated with two very good programs). His beef was that we do EVERYTHING related to a discharge. We do the discharge instructions, discharge medication rec, discharge summary. All the attendings do is review, minor edit, sign.

He told us that these should be responsibilities of attendings, since this is a main component to the hospital receiving payment (he said the reimbursement is $150 for just the discharge summary).

A discharge usually takes up 30 minutes, but on a busy service you can end up w/ 3-4/day. (I did 17 in a 3 day span once). He told us this is time we should be learning/reading. This is unnecessary SCUT work for us. But this is the way it has always been at our program.

At my program, residents did all the notes and orders starting intern year! These were Psychiatry DC summaries with novel-like hospital courses. If we complained about anything at all, we would be awarded an extra call my our PD and Chief. Keep your head down and do your work.
 
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Raryn

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I recently attended a pharm dinner hosted by a (doctor) father of a co-intern's and afterwards he spewed so much disdain for our duties as interns. (He is affiliated with two very good programs). His beef was that we do EVERYTHING related to a discharge. We do the discharge instructions, discharge medication rec, discharge summary. All the attendings do is review, minor edit, sign.

He told us that these should be responsibilities of attendings, since this is a main component to the hospital receiving payment (he said the reimbursement is $150 for just the discharge summary).

A discharge usually takes up 30 minutes, but on a busy service you can end up w/ 3-4/day. (I did 17 in a 3 day span once). He told us this is time we should be learning/reading. This is unnecessary SCUT work for us. But this is the way it has always been at our program.
Your job as a resident is to learn how to do all the work, including the paperwork. In fact, for any inpatient service that isn't primarily procedural, I'd say the discharge med rec is probably the most important thing you do for the patient. The attendings job at an academic program is to teach you how to do it, do their own clinical work, do research if that's part of their position, and assist in the running of the department. Part of the reason why people take jobs at academic programs (and take a usually very substantial pay cut in order to do so) is to A) give them time for the other parts of that job and B) have minions (that's you) to do the frustrating/annoying parts of the process.

At our program, the intern (under the supervision of a senior resident) does the discharge instructions and med rec. Depending on how long the patient was there, either the intern (for short stays) or the senior resident (for longer stays) will do the d/c summary. Other programs interns do all the d/c summaries. In no training program I'm aware of does the attending do them all.
 
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mimelim

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At our program...

The expectation is that the most junior member on the team will discharge the patients. Most of the time that means interns. But, today I was on call and discharged 3 patients (I am a PGY4) and the fellow (PGY6) discharged 1. It is just a matter of getting patients out of the hospital. I doubt our attendings have discharged a patient themselves in decades. It takes me all of 2 minutes to write the orders, maybe 5 minutes to dictate the discharge summary and maybe 3 minutes to do the med rec, so maybe 10 minutes per discharge. Granted, anyone with any semblance of medical complexity is not going to be on my service (because I won't admit them to us in the first place). I don't think interns get supervised on discharges after maybe the second week in July. I'm not saying that that is the correct way to do it, but it is simply the reality of a service that does 60-80 cases a week.

Now, we rotate on a major PRS service (15 attendings) that is part of a major university teaching program. Their attendings do every single discharge themselves. Part of it is that they have a private practice model in place, the other part is that they like their billing/coding to be perfect, which you will never get with residents.
 
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NotAProgDirector

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Discharge is being increasingly recognized as one of the most dangerous parts of inpatient care. Once the patient is discharged, there's no chance to pick up on errors (i.e. missing or extra meds, wrong doses, etc). So some programs are encouraging/forcing faculty to be present and participate in the discharge process run by housestaff -- probably a good thing.

From a billing standpoint, discharge is billed based on time -- but ONLY the faculty time counts. If a resident spends 45 minutes working on a discharge and I spend 5 minutes reviewing it, I only get to bill for the 5 minutes. If faculty are billing for resident time, that's medicare fraud. If you'd like to work with me and be a whistleblower in your program, we could get rich. But your career would probably come to a screeching halt. So there's that.
 
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Raryn

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Discharge is being increasingly recognized as one of the most dangerous parts of inpatient care. Once the patient is discharged, there's no chance to pick up on errors (i.e. missing or extra meds, wrong doses, etc). So some programs are encouraging/forcing faculty to be present and participate in the discharge process run by housestaff -- probably a good thing.

From a billing standpoint, discharge is billed based on time -- but ONLY the faculty time counts. If a resident spends 45 minutes working on a discharge and I spend 5 minutes reviewing it, I only get to bill for the 5 minutes. If faculty are billing for resident time, that's medicare fraud. If you'd like to work with me and be a whistleblower in your program, we could get rich. But your career would probably come to a screeching halt. So there's that.
One Saturday in the ICU, I added up the amount of critical care time the cross-cover attending (who was covering two full MICU teams) documented (and presumably billed for). It was a busy day, so the two services had ~35 patients between them... and the average documented # was something like 45 minutes. And of course, none were less than 30 (or you can't bill for critical care time). I promise you that the attending didn't spend 26 hours rounding that day.
 

NotAProgDirector

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One Saturday in the ICU, I added up the amount of critical care time the cross-cover attending (who was covering two full MICU teams) documented (and presumably billed for). It was a busy day, so the two services had ~35 patients between them... and the average documented # was something like 45 minutes. And of course, none were less than 30 (or you can't bill for critical care time). I promise you that the attending didn't spend 26 hours rounding that day.

I kid you not, if you bring this to the attention of Medicare they will happily prosecute, and you will get a big fat cut of the proceeds.
 
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mvenus929

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At my program, all the intern-level people do the discharges (we have second years that come back to do 're-tern' time on certain teams). On our hospitalist team, interns do not do discharge summaries, as the attendings dictate them directly, but we handle all the prescriptions, discharge instructions/progress notes, and mec recs on our own. Occasionally, the attending will be the one to place the order, if we are in conference for instance. For all other teams, the discharge summaries are co-signed by the attending.
 

jthedestroyr

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Every rotation I've been on, it was expected that the intern does the discharge summaries ( ICU, surgery wards, medicine wards). I thought this was standard that intern's do scut work like this.
 

Law2Doc

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I recently attended a pharm dinner hosted by a (doctor) father of a co-intern's and afterwards he spewed so much disdain for our duties as interns. (He is affiliated with two very good programs). His beef was that we do EVERYTHING related to a discharge. We do the discharge instructions, discharge medication rec, discharge summary. All the attendings do is review, minor edit, sign.

He told us that these should be responsibilities of attendings, since this is a main component to the hospital receiving payment (he said the reimbursement is $150 for just the discharge summary).

A discharge usually takes up 30 minutes, but on a busy service you can end up w/ 3-4/day. (I did 17 in a 3 day span once). He told us this is time we should be learning/reading. This is unnecessary SCUT work for us. But this is the way it has always been at our program.
Four problems with this post:
(1) no organization wants the most expensive/ valuable personnel dealing with scut. You want him supervising. There is value in hierarchy.
(2) scut is in the eye of the beholder anyhow -- doing notes, discharges, examining the patients isn't scut. There is actually a lot more value "doing" rather than "reading" as an intern, whether you want to believe it.
(3) you are a better doctor if throughout your training you learn how to do every task. The goal isn't to have you do 3+ years of training so you can do what the guy right out of med school is perfectly qualified to do. In every profession there's a "work your way up from the mail room" logic. You seem to think you can read for a few years and magically be an attending. You really need to crawl before you are ready to walk and this is part of the crawling.
(4) finally I think someone hosting a pharm dinner (an inherent conflict of interest) is probably the wrong person to take advice from in terms of what is appropriate for billing reasons.
 
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Doctor4Life1769

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It's "uneccessary scut" for you...but somehow the attendings should be doing it for you?

Wut?

Glad to see the attitude of "my job" = "scut" has elevated from entitled medical students to entitled residents.

What's also as bad, if not worse, is what L2D alluded to - that a physician who is clearly in it for greed is telling wet in the ear residents/interns that the basic premise of patient care is considered "scut"
 
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michaelrack

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From a billing standpoint, discharge is billed based on time -- but ONLY the faculty time counts. If a resident spends 45 minutes working on a discharge and I spend 5 minutes reviewing it, I only get to bill for the 5 minutes. If faculty are billing for resident time, that's medicare fraud. If you'd like to work with me and be a whistleblower in your program, we could get rich. But your career would probably come to a screeching halt. So there's that.

true, but the reimbursement is the same for 1 second to 29 minutes, 59 sec (99238). So there usually should be no problem for the attending to bill a 99238 as long as he had some involvement in the d/c (such as telling the intern to d/c the pt)
 

Gastrapathy

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I can just picture a pharma shill who has 2 NPs doing all of his inpatient charting saying those words. Doing the work isn't scut. This is no different than any other part of the hospital stay except that its what stays with the patient and a bad discharge will lead to a bounce or worse. You'll catch countless meaningful errors if you do discharges correctly (but if you view it as scut, maybe you won't notice the patient who came in on coumadin, was switched to pradaxa and now thinks he's taking both).
 
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dpmd

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I kid you not, if you bring this to the attention of Medicare they will happily prosecute, and you will get a big fat cut of the proceeds.
If there was a way to only get certain people at a program in trouble I would consider this,but unfortunately I think it would lead to a big audit and the whole place would suffer.
 
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HooliganSnail

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I can just picture a pharma shill who has 2 NPs doing all of his inpatient charting saying those words. Doing the work isn't scut. This is no different than any other part of the hospital stay except that its what stays with the patient and a bad discharge will lead to a bounce or worse. You'll catch countless meaningful errors if you do discharges correctly (but if you view it as scut, maybe you won't notice the patient who came in on coumadin, was switched to pradaxa and now thinks he's taking both).

Paperwork is ALWAYS scut.
 

medimedimedi

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LOL At my institution, med students do them too (along with admission notes, daily notes, placing consults, etc). As a 3rd year, I wrote discharge summaries AND did the medication reconciliation signed in as the resident. They might addend the discharge summary later.
 

atomi

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New interns should not be doing discharge med recs and discharge summaries unsupervised. These are the two most important parts of the discharge and screwing them up harms the patient and lands them back in the ED 2 days later. And I'm tired of reading discharge summaries that are just a bunch of pre-populated lab values nobody cares about with the last progress note copy-and-pasted as the discharge summary, which itself was just a daily copy and paste of notes over the past 2 weeks ending up in a mess of irrelevant garbage. If I can't find the date of discharge in 2 seconds of opening your discharge summary, you've failed. If I can't find the hospital course in 3, you've really failed. The only people who do worse discharge summaries than first month PGY-1s tend to be NPs.

My discharge summaries were always excellent and I put a lot of time in them. My feedback was always, "wow, not only is this not horrible, it's actually good." Kind of like they expected it to be horrible. Well of course they do, because everyone gets away with it.
 
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Doctor4Life1769

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New interns should not be doing discharge med recs and discharge summaries unsupervised. These are the two most important parts of the discharge and screwing them up harms the patient and lands them back in the ED 2 days later. And I'm tired of reading discharge summaries that are just a bunch of pre-populated lab values nobody cares about with the last progress note copy-and-pasted as the discharge summary, which itself was just a daily copy and paste of notes over the past 2 weeks ending up in a mess of irrelevant garbage. If I can't find the date of discharge in 2 seconds of opening your discharge summary, you've failed. If I can't find the hospital course in 3, you've really failed. The only people who do worse discharge summaries than first month PGY-1s tend to be NPs.

My discharge summaries were always excellent and I put a lot of time in them. My feedback was always, "wow, not only is this not horrible, it's actually good." Kind of like they expected it to be horrible. Well of course they do, because everyone gets away with it.

Where are the upper level residents to go through them?
 

hamstergang

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They might addend the discharge summary later.
At some point in residency, I was quite shocked to discover that 'addend' is a noun only (and it refers to numbers being added together) and not a verb. The word/phrase you're looking for is 'make an addendum' or 'append.' I wish we could change this but I haven't been successful yet.
 
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Gastrapathy

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The worst discharge summaries read like a 5 year old telling a story:
and then the patient needed an enema and then she fell and then she had a CT scan and then we called neurosurgery and then they said...
 
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Raryn

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I've done my fair share of chart review for research, and IMO the best discharge summaries are dictated ones that just give you the general story of why the patient was there. If I wanted every lab and imaging result, I can just go back and find them.

The worst are the ones we're putting out now, especially with the new templates the hospital made since the advent of "problem based charting." Everything is getting more and more templated and harder and harder to read.
 
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atomi

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I've done my fair share of chart review for research, and IMO the best discharge summaries are dictated ones that just give you the general story of why the patient was there. If I wanted every lab and imaging result, I can just go back and find them.

The worst are the ones we're putting out now, especially with the new templates the hospital made since the advent of "problem based charting." Everything is getting more and more templated and harder and harder to read.

We really need a ban on pre-populated lab values at the institutional level. Lab values don't have to be in the note. If you feel they are significant enough to include, you should type them by hand. This is what I would do.

E.g.,

AM labs reviewed. Notable for Hgb drop to 8.0 from 9.5 yesterday.

That's IT!
 
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BigRedBeta

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Novel length discharge summaries are the absolute worst...

"Patient went on VA ECMO on 3/21, removed from ECMO on 3/27"

That should be the extent of it...and you probably don't need to specify it was VA

However as an attending in private practice, you'll have to do your own discharge activities and if you don't have the practice being efficient, you'll waste a lot of time you could be doing other things, if nothing else going home to see your family. I can't understand people who complain about never leaving the hospital but never seem to light a fire under themselves to get work done during the day.
 
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