Report on performance
Scenario 12
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 So the history that you would have taken from her on that particular day?
Practitioner Well, probably at that particular time she would have indicated that she had got Hepatitis C and I probably would have had a discussion about the various things involved with trying to manage that condition.
Committee Member Okay. What examination did you perform for this patient?
Practitioner Well, the same sort of thing. I think I would have examined her spine to see whether or not things were getting better or worse. So I would have, at the very least, palpated the spine and done straight leg raising.
Committee Member And what were the results of those examinations?
Practitioner Well, I can only assume that because I haven't recorded the results that there was nothing untoward.
Committee Member I see. And your management plan for this patient?
Practitioner Well, it was just to continue on with the Kapanol.