Nursing triage/assessment questions, history, and patient satisfaction

[LaBusqueda]

So, the physicians get an email lately from the ED nurse manager. To sum it up it states that in light of overwhelming patient "experience" feedback she would like us to please use the information attained from the nurses (by the time we see them it is triage and then the room nurse most of the time) for certain aspects of the CC and Hx!!
Patients are evidently rating the fact that we have the gall to go and repeat the questions already asked by RNs. The info that our nurses get is opqrst, and all the past Hx stuff, mess, etc... Standard stuff and then the BS public health crap
Now, I hope that most would be with me, but I don't care how many people ask or write down stuff, I am getting my own history. PERIOD. Even bringing this up is not appropriate. We let them know this, and it's handled, for now.
We are a SDG, I hope other, particularly CMGs, are not setting a precedent here.
I cannot even begin to recall the vast amount of times my history varies in rather important ways from that on the chart.

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[alpinism]

If your patients don't like being asked stuff twice they should come on over to an academic hospital ED.

Nurse --> med student --> resident --> attending --> IM admitting med student --> IM admitting resident --> IM attending

But yes, asking physicians to use nursing HPIs is beyond ridiculous.

Just another reason why patient satisfaction scores do more harm than good.

 

[Angry Birds]

I think patients who complain about having to provide a history twice are obnoxious. Like Alpinism said, at a university hospital the history will be asked multiple times. Whenever I transfer a patient to a university hospital, I warn them about this, but I reassure them that they are usually getting the best care at university hospitals and that usually residents are very conscientious--that their added care is actually a good thing.

However, as you progress through your career, you *will* rely on the nursing note for certain aspects of the history, such as medication list. (Good luck trying to get that yourself!) I also hate how patients ramble, so reviewing the nursing note allows me to ask more focused questions... I make it a point to comment on their chief complaint when I first open up, so that they know that I at least read the nursing note myself.

 

[Doctor Bob]

So, the physicians get an email lately from the ED nurse manager. To sum it up it states that in light of overwhelming patient "experience" feedback she would like us to please use the information attained from the nurses (by the time we see them it is triage and then the room nurse most of the time) for certain aspects of the CC and Hx!!
Patients are evidently rating the fact that we have the gall to go and repeat the questions already asked by RNs. The info that our nurses get is opqrst, and all the past Hx stuff, mess, etc... Standard stuff and then the BS public health crap
Now, I hope that most would be with me, but I don't care how many people ask or write down stuff, I am getting my own history. PERIOD. Even bringing this up is not appropriate. We let them know this, and it's handled, for now.
We are a SDG, I hope other, particularly CMGs, are not setting a precedent here.
I cannot even begin to recall the vast amount of times my history varies in rather important ways from that on the chart.

Trust but verify.

If patient's don't like it, they are free to go to their primary care doctor instead.

 

[deleted480308]

Unless that email also included the guarantee of coverage from the nurses new malpractice policy and a letter from the medical board lawyer granting you immunity....I'd tend to tell the nurses I'll get my own questions answered.

 

[Birdstrike]

So, the physicians get an email lately from the ED nurse manager. To sum it up it states that in light of overwhelming patient "experience" feedback she would like us to please use the information attained from the nurses (by the time we see them it is triage and then the room nurse most of the time) for certain aspects of the CC and Hx!!
Patients are evidently rating the fact that we have the gall to go and repeat the questions already asked by RNs. The info that our nurses get is opqrst, and all the past Hx stuff, mess, etc... Standard stuff and then the BS public health crap
Now, I hope that most would be with me, but I don't care how many people ask or write down stuff, I am getting my own history. PERIOD. Even bringing this up is not appropriate. We let them know this, and it's handled, for now.
We are a SDG, I hope other, particularly CMGs, are not setting a precedent here.
I cannot even begin to recall the vast amount of times my history varies in rather important ways from that on the chart.

This illustrates the fraud that is patient satisfaction surveys, and the ways in which they are used to taunt physicians and degrade patient care, for profit. You were downgraded for providing better care (verifying history, which is your duty) than the substandard care the patient didn't even realize they were demanding (to take a chance by not verifying history, and not due your duty as a physician).

 

[LaBusqueda]

Indeed. I have always looked at the nursing chart.

I agree that patients who complain about this are ludicrous. That's suburban community EM for ya.

As Bird mentioned, managers and non clinical people are just trying ANYTHING they can do to boost this worst of metrics.

 

[Angry Birds]

Also, always always make sure to read the nursing notes so that you don't miss something and/or you correct any discrepancies. For example if the RN note says "baby appears listless and floppy", if that's not the case you better mention it in your note!

 

[erdoc00]

What a joke this has become. It's gotten to the point that reality is indistinguishable from satire.

 

[LaBusqueda]

What a joke this has become. It's gotten to the point that reality is indistinguishable from satire.

So true, I thought I was getting an email from Gomerblog!

 

[EM Junkie]

Why not work with nursing to better the system? A "quick look" triage can be performed, followed by a nurse/physician team to get the rest of the history.

Or just tell the patients: "I'm sorry you've had to tell this story before, but this is the only time that matters."

 

[SoCuteMD]

I think part of what patients want to know is that we've actually bothered to read what they've already told people. They want to think that we value their time and effort (especially when they aren't feeling well).

When I sense a patient is tired of starting all over, I'll say, "How about I'll tell you what I've read so far and you can feel free to interrupt me or correct me at any time." They usually interrupt to correct me on some small detail ("It's chest PRESSURE, not pain) and then continue the story from there. I get the info I need, they get to feel like I did some research on them before I walked in the room, they are happier (and therefore more cooperative) and we both win.

 

[RustedFox]

I usually have the triage chart in my hands (its what I scribble on) and start with:

"So, they give me a short cheat sheet on you, but I have to get the whole story. It says here... Chest pain for 3 hours..."

It's the "lack of communication" that they sense that upsets them.

 

[WilcoWorld]

Rusted Fox and SoCute's suggestions are good, and I have found them to mitigate patients' frustration. But that doesn't change the fact that the email LaBusqueda got is every bit as believable as it is asinine:

What's that? The patients don't like having to tell their story twice before they get to see the doctor? I know how to fix it, let's tell the doctor to stop asking so many questions! Also, remember to communicate with your patients!

 

[LaBusqueda]

I know we are all smart folks and yes we all get around doing it. I do a similar thing, like we all do.
The point was really to illustrate the rather silly lengths admin is gong to for this.

 

[RustedFox]

I know we are all smart folks and yes we all get around doing it. I do a similar thing, like we all do.
The point was really to illustrate the rather silly lengths admin is gong to for this.

Yeah, you're right on - I was totally missing the point.

Last year, a then-director asked me what could make my job easier from a management standpoint.
I'm not sure what I said then (can't remember), but I'm sure that my answer now would be:

"Just let me do my job. Leave me alone; and let me do the doctoring. Don't complicate everything."

 

[LaBusqueda]

Yeah, you're right on - I was totally missing the point.

Last year, a then-director asked me what could make my job easier from a management standpoint.
I'm not sure what I said then (can't remember), but I'm sure that my answer now would be:

"Just let me do my job. Leave me alone; and let me do the doctoring. Don't complicate everything."

Like^10

 

[BJJVP]

Does anybody know if all the info collected by the RN is legally required somehow? It seems a bit redundant to me. Definitely the med/allergy list helps. But, I often go in before the RN and rarely do I need anything else. Sometimes, things like a recorded pain rating helps for billing. But do they really need to do all that question asking and charting? I feel that pt care is really compromised by the amount of busy work nurses have. That's why I can get the pts their blanket, pillow, and meals faster than a lot of the RNs.

 

[RustedFox]

Like^10

Now that I think more about it, I can remember his exact words: "What can we do to "manage you up" to achieve our goals?" (with specific reference to the metrics)

Still can't remember my response then, but my overwhelming response now is "Then shut up and get out of my way."

We have a new site medical director now, who isn't afraid to make it CLEAR to administration that you can't get blood from a stone.

Administration did, however - step up to the plate and upstaff the ED to the point where we can achieve an arrival-to-greet time of 15 minutes or less. We now have shift overlap and plenty of MLP support to see the low-acuity "convenience department" patients.

Here's the real pisser: our across-town competitor opened an urgent care just blocks away last year sometime. All it did was drive our census up, because paying upfront for care is... well, just outrageous!

 

[MSmentor018]

I usually have the triage chart in my hands (its what I scribble on) and start with:

"So, they give me a short cheat sheet on you, but I have to get the whole story. It says here... Chest pain for 3 hours..."

It's the "lack of communication" that they sense that upsets them.

I use to do the same...until they took the triage charts away from us

 

[b-real]

Does anybody know if all the info collected by the RN is legally required somehow? It seems a bit redundant to me. Definitely the med/allergy list helps. But, I often go in before the RN and rarely do I need anything else. Sometimes, things like a recorded pain rating helps for billing. But do they really need to do all that question asking and charting? I feel that pt care is really compromised by the amount of busy work nurses have. That's why I can get the pts their blanket, pillow, and meals faster than a lot of the RNs.

There has to be info that's legally required. Why else would they ask "sir, do you feel safe at home?" before I get to do the primary survey in a trauma?

 

[GeneralVeers]

There's primary care garbage that the governments and hospitals have sloughed off on the ED. Why do we do "Fall Risk Assessments" on healty 18 year olds? Moreover in the ED setting who cares? All these questions are a complete waste of time and result in worsening inefficiency in the ED and piss the patients off on the process.

 

[gutonc]

There's primary care garbage that the governments and hospitals have sloughed off on the ED. Why do we do "Fall Risk Assessments" on healty 18 year olds? Moreover in the ED setting who cares? All these questions are a complete waste of time and result in worsening inefficiency in the ED and piss the patients off on the process.

If it makes you feel any better (and it shouldn't, except in a Schadenfreude sort of way), subspecialists have to put up with this bulls**t too.

 

[engineeredout]

I always read the triage note before seeing a patient, because it can provide useful information. What is slightly less useful is the mandatory Ebola screening still being performed on every single patient walking into the emergency department, whether it's an ankle sprain or an MI. The screening questions take up about a full page in the triage note.

 

[deleted547339]

If it makes you feel any better (and it shouldn't, except in a Schadenfreude sort of way), subspecialists have to put up with this bulls**t too.

In a twisted kind of way, it does.