We all know how to bomb a survey. If you missed my explicit instructions, click here. But without bombing a survey because of blatant disregard for the regulations, there are a number of tags that I see repeatedly at agencies that should never happen.
The first and easiest is to write orders and not follow them. To wit, ‘weigh patient q visit and report weight gain of x pounds’. My first issue with tags related to these orders is that many of them do not need to be written at all. But if they do need to be written, they must be followed.
There are two ways to deal with these types of orders. The first is to write a blanket order for every patient and verify that weights are on each and every note. Generally speaking in my experience, it takes about three months for a new process to be implemented and followed consistently. The second way to deal with these types of tags is to be very careful about writing unnecessary orders and then monitor those patients’ charts weekly. Either way, it is a given that some patients must be weighed in order to deliver appropriate care. Your processes must protect these patients.
Another tag that is very common and should never be seen relates to medications. It is not at all unusual for a visit note to state that a patient’s pain is relieved by Tylenol, Advil or some other pain medication and yet, when reviewing the medication profile, the medication is not listed.
This is a serious tag. On a grand scale, giving a patient medications that are not ordered puts your patients at much greater risk than weighing a patient who really doesn’t need to be weighed each visit. Consider that Tylenol may cause liver damage and since home health patients are typically on numerous medications that are metabolized by the liver it is important to consider even seemingly benign medications in the context of an entire medication profile. Additionally, some narcotic pain meds such as Darvocet and Percocet already have Tylenol as a primary ingredient and therefore, an overdose situation may occur if the patient takes OTC Tylenol for breakthrough pain.
Finally, one of the most frequent tags that I see is related to coordination of care. This is largely a documentation error but a serious one. If important changes to the plan of care or the patient response to treatment are not documented, it can compromise care. Although most times, staff is aware of these changes, we must always be prepared for the time when emergency situations exist and clinicians MUST rely on the written information available. As someone who has lived through numerous hurricanes in the past few years, I can assure you that every piece of documentation counts when a patient is separated from their usual caregiving staff and family.
If you spend most days in the field, make your life easier by weighing patients if you are uncertain of the orders. If you encounter an order for a patient who cannot weigh, document why and send a change order to the physician so the order can be discontinued. When anything at all happens to a patient that is not captured on a visit note, document it. Anyone who complains to you about too much documentation is generally not worth listening to as long as your documentation is accurate and timely.
As always, if you have any questions or comments, we are delighted to hear them. If you see any other tags with alarming frequency, send them my way to include on the blog. Your comments may be posted below and we are available by email at firstname.lastname@example.org.