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What Were They Thinking

That is the question that runs through my mind when I review charts at agencies that do not have good quality review processes.

For instance, does the nurse who is teaching on Lortab know that the patient really doesn’t have an order for it on the plan of care?

What about the nurse teaching on Lasix for the sixth consecutive visit? How concerned is a nurse about her patient files a missed visit report but no follow up? Is the patient just laying there on the floor unable to answer the door? These are the questions that go through my mind when I read charts.

Then there is the documentation that is supposed to work as a catchall but actually serves as a ‘catch nothing’. Imagine reading on a chart of a patient with 22 medications that the nurse ‘taught side effects of meds’. That’s a lot of teaching for a single home health visit. It may have been a better use of time to choose one or two high risk medications and teach on those.

So are these just really crummy nurses? No. Does their documentation truly reflect the quality of the care they provide? I think not.

And it isn’t that these nurses are unable to learn. The problem is that it is difficult to teach an adult a skill that they have no use for. In the current regulatory environment, we are paid mainly because we send a bill to Medicare. No one is currently looking at the documentation to support claims. As such, documentation falls off on our priority list.

Can we say with any confidence that this will always be the case? Of course not. Too much attention is being placed on health care reform and how we are spending our Medicare dollar for us to expect the current level of scrutiny to continue.

And when the feds do come looking, it will likely be for clinical records that have long since been closed. In other words, the work you are doing now could be the subject of future reviews. Is your agency ready for that?

I hope so. If not, give us a call and we will get you ready. On the other hand, once the feds arrive, it may be too late!

One Comment Post a comment
  1. elmira #

    What frightens me more, is that that money from medicare, for paid claims, might be asked to be returned, beause of poor documentation. It is absolutely very important to QA charts. Thank you for your blog.

    May 20, 2010

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