Question

1. A 50-year-old woman has been experiencing a chronic cough for the past two months. She is a two pack per day smoker and has been for the past 30 years. She sees her PCP for the cough and is given an order for a chest x-ray at the local hospital. The x-ray report states, “nodule in lower lobe of right lung, worrisome for malignancy.” The PCP refers her for a biopsy of the nodule at the ambulatory surgery clinic, which substantiates the diagnosis of cancer in the pathology report. Two weeks later the same physician who did the biopsy performs a right lower lobectomy. Prior to discharge after surgery, the patient develops an infection, and the infectious disease specialist is asked to evaluate her and recommend the appropriate treatment course. Upon discharge, she receives care in her home for the next two weeks. Four weeks after surgery, radiation therapy is initiated, but her condition continues to deteriorate over the next few months with metastasis to the brain noted, at which point she decides to receive only palliative care.
   1. Classify the providers for each stage of the patient’s care noted above and outline their responsibilities.
   2. Explain the documentation that each provider will be creating as part of the patient’s record.

Answer 1

1. PCP( primary care physician) is the first contact of a person with undiagnosed problems . They assess the patients and diagnose the disease. Later, if necessary they refer the patients to specialists for further treatment.

2. Ambulatory surgery clinic physician

A specialist in managing various surgical patients . These specialists performs biopsies and surgeries.

3. Infectious disease specialist ( The doctor who is mainly specialised in managing infectious diseases). He treats the infection and related problems .
4. Palliative care ( mainly cares the terminally ill patients). Palliative care provides better quality care for the people with serious illness.

DOCUMENTATION

1) PCP

History and physical examination ,  Documents abnormal previous lab reports and serious medical problems, orders diagnostic tests and procedures, prescribes medicines for the current medical condition, identifies the abnormal lab values and findings and refer the patients to the specialists ( if necessary)

2) Surgical clinic physician

Documents the referal and it's reason , identify the need of diagnostic and therapeutic procedures, documents the findings of biopsy and surgery, prescribes medications, documents the preoperative, intraoperative and postoperative findings , provides discharge summary with discharge advice.

3) Infectious disease specialist

Documents the need of specialised care, orders further laboratory tests, documents the diagnostic findings, prescribes medicines and provides follow up measures .

4) Follow up after the discharge at clinic

Documents the present condition of the patient , plans further care ( radiation therapy etc),  prescribes medicines and lab tests.