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Documentation – Again!


So, I am sitting at my desk reviewing clinical records for any number of reasons for any number of clients.  The ZPIC charts are the ones that tell the story.  It isn’t that they are any worse than any of the others.  Rather, they are the only ones that are reviewed in their entirety through multiple admissions and discharges for a period of two to three years.  That’s a lot of visit notes.

So, today, I am reading a chart of a 95 year old patient and when I start on episode three I noticed that she had fallen.  I jumped up from my chair and yelled with excitement.  Finally, something happened to the patient that warranted continued services.

Yes, folks.  That’s how low I’ve fallen in these dark days of clinical record review.  I am now celebrating when a 95 year old woman falls to the floor.  I find this mildly discomforting.

Now, just like all the other charts and all my other clients, when I call the nurse, I hear all sorts of things.  The patient had lost her medications for a few days or there was an unstable caregiver situation and numerous other things that warrant care from a home health agency.  But they are not in the chart.

And before I go to these agencies fully armed and ready for action, I have to have one of those talks with myself.  The vast majority of my clinical background is in the CCU’s.  I am proud to say that patient care always came first with me but I seriously doubt that my documentation would have withstood the kind of scrutiny that our small sector of the industry is subject to now.  I am once again reminded how there is often very little correlation between quality of care and quality of documentation.  Some of us just have better things to do.

And in the interest of fair disclosure, let me say that I really don’t know a whole lot of nurses who have lost their license, been sued and have their lives ruined because of poor documentation.  There is a really good chance that your documentation will never result in such a drastic outcome.

But I do know some nurses and agency owners and others who are in jail.  I know some nurses who are struggling to feed their families because they lost their license and we really aren’t qualified to do much else.   I know of a nurse who charted pedal pulses on a bilateral amputee.  She wasn’t trying to commit fraud.  She simply charted the same thing she always did out of habit one night when she was tired.  It didn’t help that her lawyer said to the state board of nursing, “So, you are telling me there is no place else in the body that you can have pedal pulses?”

So, the choice is yours.  You can play the odds and hope they stay in your favor or you can document correctly.  If you think about it, the odds are also in your favor should you choose to play Russian roulette.  You don’t play the odds with your life and you shouldn’t play the odds with your career.

Now I will get back to work and hope that the 95 year old falls again or better, gets an infection with a whole lot of medication changes.

8 Comments Post a comment
  1. Anita #

    Very funny and honest! I can totally relate about feeling akward when you’re happy to find problems with a patient that justify care. It’s the sad plight of a chart reviewer! Thanks for the smile!

    Like

    July 1, 2011
  2. Mike #

    I tell my staff, their notes are a receipt for payment; and the people that bring you the FBI and IRS are the same ones that bring you Medicare…..

    Like

    July 1, 2011
    • I love that. It’s so funny. I am going to put it in my PowerPoints for when I do training on documentation. Do you mind? I always tell my clients that any agency with three letters and a bird can bring a world of hurt! FBI. DOJ. IRS. OIG. CIA. CMS……..

      Like

      July 1, 2011
  3. I know, I know. Anyone who shares the joy of chart auditing can relate. Ugh. I hope that I have never done anything like that, but I remember coming back to the office more than once and not being able to picture my patient. Some days are like that. One reason why I always took notes. Pedal pulses. Wow that is sad.

    Like

    July 1, 2011
    • I had a couple of bad days like that in the field. The experience taught me well. Always document in the home. I was reading charts one day and there was a case conference where the visit note was supposed to be. It read something to the effect that the nurse didn’t remember visiting the patient but it was evident the visit was done because the lab ordered for that visit was on the chart. Turns out it was all true but maybe whoever wrote that note should have included that the nurse’s memory was impaired by the head injury she sustained that day in a motor vehicle accident.

      Like

      July 1, 2011
  4. Millicent #

    I can relate! My added frustration is when information like this is shared, I get the feeling that I am the ‘OGRE’from outer space.

    Like

    July 14, 2011
    • Its all a matter of perspective. People don’t call a consultant because of all the good charts they have. They call me when they are in trouble. So, I have seen more nurses than most get into serious trouble. Even when they get out of trouble, the anxiety, stress, consulting and lawyer fees are enormous. Don’t get me wrong. Billing clients is one of my favorite things to do. But there are so many other projects that I would prefer to be doing for my clients. And to see what a good nurse has written or done and to know that there is nothing I can do to help her is a very bad feeling. Worse for her, I’m sure.

      Like

      July 14, 2011
  5. Sherry Falls #

    I wish you would follow up on this blog as it is connected to the number of visits that nurses are required to do on a daily basis. The “p” word – productivity is the game, as nurses will work off the clock to try not sink in case management and oasis issues. Somewhere in the world a daily productivity of 5.3 patients came around. However with the growth of paperwork and regulations, many nurses who are fighting to be there for their families in the evenings, work on paperwork out of fear. Home Health turn over is high because of this continued lie. You can’t tell nurses that they can completely finish 2 IAs and a visit, fully coding and and doing 485 and 486 within 8 hours everytime. I had a director who said that to do an IA you should stay in the home about 30 to 45 minutes then finish the paperwork later. Hum, check meds and do an assessment and ask oasis questions and go over plan of care in 45 minutes. How do we turn this lie around, without going to Labor Boards, etc. I toldly believe that sometimes doing less turns out to be more money in the bank, if you focus on getting quality and consistency first, and building from there.

    Like

    December 4, 2011

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