Long-Term Care Survey Alert

Published on Thu Jul 28, 2005 PDF

Faxing assessment forms helps meet physician notification requirements.

Playing phone tag with physicians won't get you far in providing timely care - or in warding off F tags for negative clinical outcomes.

To ensure physicians get the data they need to make informed clinical decisions, develop faxable assessment forms for common conditions, such as pressure ulcers, dehydration, diarrhea, fever, etc., suggests Clare Hendrick, ARNP, in San Clemente, CA.

Nurses can use the forms in all cases to gather the requisite assessment data. Then the nurse can call the physician and fax the additional information if the physician isn't available to talk at the time. "Implementing that process can help meet regulatory requirements for facilities to notify the physician" of a resident's change in condition," says Hendrick.

Facilities can maintain the completed assessment forms in the chart as a reminder to physicians and nurses during physician visits that the resident had a problem or change in status. "That way, the staff can make sure the resident received appropriate follow-up, if needed, and easily detect patterns signaling a recurrent or emerging clinical issue," counsels Hendrick. "Physicians don't always read the nursing notes," she adds, "but the forms stand out in the chart." (See p. 90 for an example of a faxable assessment form for diarrhea.)

Risk management tip: Call before you fax assessment information. And if the physician doesn't respond to the fax ... call, call again. "Facilities shouldn't assume a fax went through to a physician," cautioned Daniel Haimowitz, MD, CMD, in Levittown, PA, in an AMDA presentation in Nashville, TN. "If you have an abnormal lab result, for example, you have to make sure the physician receives it - don't rely solely on technology."