Report on performance
Scenario 11
Service claimed
MBS item 36 - Professional attendance involving taking a detailed history, an examination of multiple systems, arranging any necessary investigations and implementing a management plan in relation to one or more problems, and lasting at least 20 minutes.
Record entry
Transcript of part of the discussion with the practitioner reads:
Committee Member Doctor, what were the presenting complaints at this service?
Practitioner Okay? She came in because she had palpitations, she is unsteady on his feet, okay, and her balance is no good.
Committee Member This is not written on your records.
Practitioner Is written on November 12, 2003.
Committee Member Yes, but we are looking at 16 December. Can you please ---
Practitioner Basically - December 16 is basically her problem of unsteady on her feet has not corrected. She is still unsteady.
Committee Member What examination did you perform? You took her blood pressure?
Practitioner We do - went through we check her lungs, her heart, we check abdomen, her blood pressure.
Committee Member Again nothing is recorded.
Practitioner I tick a short form of MX, medical examination so that I don't have to type all those things in.
Committee Member But you have got MX on all the consultations for this patient from when your records first start? So what does MX actually mean?
Practitioner We basically take the blood pressure, take the pulse, we examine the lungs, we examine the heart, we examine ---
Committee Member On every occasion that you see the patient? Surely there is no clinical indication for this at every consultation.