The contract Physician shall be responsible for providing comprehensive health care to geriatric patients in the Geriatric Primary Care and Geriatric Consult clinics. Services shall include, but are not limited to the following: Evaluation of patients- Evaluates patients who present for care, which includes the following: Completion of a detailed and complete history and physical examination consistent with the patients’ presentation. Ordering and interpreting appropriate diagnostic studies. Planning for follow up on studies ordered but results not available at time of disposition. Development of plan of care. Writing appropriate orders including computerized medical orders for admissions. Prescribe medication and treatment in accordance with the established medical center drug formulary. Variance from the formulary shall occur only when clinically indicated and in compliance with the procedures established.Enter all reports for incorporation into the computerized patient record system (CPRS) on the day of the visit and satisfy VHA and medical center policies and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements for documentation. The physician must possess computer skills to access and input typed data on each patient into the CPRS utilized by the VA. Four hours (per provider) of orientation to CPRS shall be provided by the VA to all new users. Establishing plans for follow-up care including appropriate consultations and appointments. Effective communication of plan of care with patient and/or family, including discharge and follow-up instructions. Ensuring appropriate disposition of patient, i.e., admission, transfer to another facility or discharge to home (complying with applicable utilization review criteria and policies).Establishing communication in the medical record with the physician to which the patient is referred or transferred; for urgent transfers communication shall be face-to-face or telephonic with appropriate documentation in the record and on required transfer forms. All legally required communication and documentation shall be accomplished. Admission of patients, which includes the following: Complete and detailed history and physical examination. Initial diagnosis of patient’s condition, and. Writing of initial admission orders consistent with the initial care plan including placing orders in the computerized medical record. Responding to all medical emergency codes. 1) Documentation requirements: Documentation of all care provided, planned or recommended including as appropriate, medical prescriptions. This information shall be entered in each patient’s medical record with a frequency that allows for timely implementation of medical plans and reflection of care provided. This includes, at a minimum, one dated and timed note for each episode of care. Consultation: Consultation shall be provided as needed to nursing staff, ancillary staff, and medical staff to assure timely, safe and appropriate implementation of all plans of care.
