As often as I can, I try to for write you, my faithful and beloved readers, a blog post that pertains to our industry. I try with varied success to make it entertaining or at least interesting. If it is neither, then maybe it is written because it is something that you really need to know. Now, you may not like my sense of humor or you may be completely bored by my posts in which case I suggest that you make use of your browser’s back or delete button. But I at least try.
Field nurses, on the other hand, do not seem to care that I am bored to tears reading their documentation. Look at the following example:
There is nothing interesting about this documentation. All of this with the exception of the teaching to take frequent rest periods and to take Lasix as ordered was on the flow sheet of the nurse. I don’t care that the patient has bowel sounds in 4 quadrants. I am so NOT interested in even and unlabored respirations. Whoa, check out that amazing blood pressure! Yippee. The patient has the same pulses that are noted on the front of the visit note.
On the other hand, I know things that you don’t about this patient. I know that she is also on potassium and I would have been interested in seeing that the patient was taught about the reasons why she needed to take her potassium as ordered along with the diuretic therapy. Do you think if a patient keeled over due to low potassium that ‘taught to take Lasix as ordered’ will cover you in court?
Would that have been better than teaching a 94 year old patient with heart failure to avoid prolonged standing? I am somewhat younger and no one has to teach me that!
What does, ‘take Lasix as ordered’ mean? Again, I know things you don’t know. I know that the patient has exceptionally poor vision, is at extremely high risk for falls and relies upon a walker to navigate in her home. (You probably guessed that.) Maybe it would have been better to teach the patient that when she took Lasix, it would be a good idea to be near ‘the loo’ as we called it in Australia. Or if she had a bedside commode to make sure it was near to her after taking her Lasix to prevent falls.
Frankly, any good pharmacist will tell a patient how medications are to be taken. It is the sole advantage of the home health care nurse to assess the patient’s ability to comply in the home environment.
Chances are if you cannot get me interested in anything you write, it is highly likely that you won’t be paid in a financial audit. And that is the truth. I am very interested in payment considerations. So, tell me a story. Prevent a fall and subsequent broken hip in an elderly patient. Teach the patient something they can’t learn by reading Prevention Magazine or watching Television. Remember that there are people out there paid to read nursing notes who have a burning desire to deny payment to your agency and I assure you that they have no sense of humor.
If none of that concerns you, think of me. Yes, it is all about me. Amuse me.
And above all, DOCUMENT WHAT YOU TAUGHT.
That’s all I have to say? What say you?
I feel your pain…… sadly, what seems to work best is… fear. Yes, I went and said it, clinicians have to be fearful of their clinical directors. Once you begin taking patients away and “reassigning” patients clinicians begin to “get it”. Save yourself all this anguish and go right for the jugular. You’ll see how fast clinicians respond.
Then and only then will you be paid for your troubles.
I refer back to ancient literature when I cannot get my head around a problem. Seems if you go back far enough, you will learn that there are no new problems. Here is one of my favorite passages from the Tao.
The highest rulers, people do not know they have them
The next level, people love them and praise them
The next level, people fear them
The next level, people despise them
If the rulers’ trust is insufficient
Have no trust in them
Proceeding calmly, valuing their words
Task accomplished, matter settled
The people all say, “We did it naturally”
Unfortunately, Lao Tzu did not manage nurses. That which makes us special creatures on this planet is also that which makes us among the most difficult to manage. We answer to a different authority than most members of the working force. A computer programmer does not decide that his code is more important than a meeting with his boss (more than once). Nobody dies if the numbers on an accountant’s spread sheet don’t add up (usually). As a nurse, first one who took care of patients and now as one who takes care of nurses taking care of patients, I am always aware of the voice of fear motivating me. But I have never been afraid of a Director. My underlying fear is that I do or teach something that ultimately harms a patient or that I become so confident that I forget that I forget how fallible I am. I do notice that as the nursing shortage seems to abate just a little, nurses are working harder to keep their bosses happy in terms of paperwork, etc. Like gravity, you cannot break the law of supply and demand.
Sometimes I would like to parade healthcare convicts in front of clients to instill fear. I want my clients to hear that a nurse say she documented six days after the visit and that’s why the wound care was accidentally omitted but it really wasn’t her fault the wound was infected or that she lost everything including her license in the year that followed. I want my clients and all my readers to hear about how the Feds actually do go into agencies with guns and tell staff to ‘back away from the computer’. That fear, while very uncomfortable is a very real thing. It doesn’t come from following a higher authority. It comes from not documenting the dedication to patient care that makes up the heart of nursing.
I know. I have talked until I am blue in the face about “take meds as ordered”. I see this on the chart all the time from a certain person. The problem is her peers sometimes follow suit. All the teaching in the world about documentation just does not seem to work with some nurses.
This was a good topic as all the topic I’ve read from Haydel consulting. Documentation has always been less than good for my agency but now with the eletronic documentation ( and a system that nothing entered can be remove) it has become a very sad and unbelievable nightmare. I have only been in homecare about 5 years and I have learned so much and I put it to use, however my team of nurses, PTs, OTs, MSWs, and HHa will not listen. I try to tell the nurses that they must use what we all learn in school about Care Plans. It has been so long since some nurse have done a CP their documentation leave alot to be desired. So for me the story above I can relate to. All I can do is be repetitive and hope that it will sink in with some of our disciplines
Dwelia, Thanks for the nice words. There are a number of limited legal ways to approach documentation. Some of my methods that I will admit to publicly are:
Reinforcement. It really is possible that one day it will sink in.
Examples: Give examples of poor charting, better charting, and superior charting. Example: Homebound related to SOB. (Big deal. Kobe Bryant is short of breath at the end of the 4th.) Homebound due to SOB with minimal exertion. (Better but subjective.) Cannot leave home due to joint pain and SOB after ambulating 15 feet. Requires cumbersome assist devices and assistance of others to leave home.
Yes, the last version took longer. So what. If nurses quit duplicating what is on the flow sheet in the narrative, they will have plenty of time to document well.
Perhaps for your next inservice you should plan a field trip to a federal prison.
WOW!!! Documentation is so important…The question
is….did the nurse visit the patient or did she just
“drive by” the patient’s house????
I found your post that you sent to Bill Borne a couple of days ago. This is Brenda Proctor (from Teche Home Health). Remember me?
Anyway, I found myself working for this company after I left Teche Home Health. In fact, I had personal conversations with the House, Senate Finance Committee’s investigators regarding my experiences at LHC as well as Amedisys.
I am following the government’s investigative findings with interest to see how much these three agencies are going to be fined. I believe that there could also be possible jail time. Anyway, I found your letter to Bill Borne to be entertaining and brave. I don’t believe that he is talking about buying out anyone at this point. He really needs to be concerned about getting himself bought out from the big house, if you ask me.