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.