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Follow Up on Documentation Quiz

The documentation quiz was so much fun.  We must do it again soon!  I loved your responses.  I must admit, the bonus question about what would happen to the agency if ever they were ZPIC’d lacked originality most times.  The words ‘denial’ and ‘jail’ came up a lot.  Someone wrote that Medicare would be confused if they saw the documentation.  Another writer wanted to know how long the patient had been extinct if they were seeing a paleontologist.  Let me stop here and tell you that although I have looked and cannot find it written anywhere, it is my strongly held belief that Medicare does not pay claims on dead people.

My favorite was from a nurse who emailed me and wrote, “So, I spend a lot of time trying to teach nurses how to document.  I really don’t enjoy as much success as I would like but it isn’t for lack of trying.  If this sounds familiar, I plagiarized it.”  I love it when someone really understands my frustrations!

The one that almost made me score a 1 on M1610 was this one:

This am your bestest post I have ever seed. I am going to notify the paleontologist of the potential for increased humor if the examples are ingested topically first thing in the morning.

Now I have to go see my doctor for severe laughoutloud developed this morning!


PS…You just can’t make this stuff up…have you thought about a book?

I would like to write a book someday but I love the blog and it will do for now.  Writing is solitary.  Blogging is like spending time with a bunch of nurses a couple of times a week.  I learn more from y’all than you will ever learn from me and I miss spending a lot of time with nurses the way I did at the hospital or the large organization down the street from me.  When I visit agencies, I am always mindful that I am on someone else’s clock so I try to stay focused on my task at hand.  Boring…….

I wanted to follow that post with examples of good documentation but I can’t.  Good documentation includes too much information that should not be published on the internet.  Plus, it occurs over the course of an episode and includes things like lab follow up, med changes in the computer, etc.  No single note is good.  If you don’t believe me, I will send you four perfect notes with the identical language in them for four consecutive weeks.

I had one response that read as follows:

I review charts daily for my organization.
I do believe the documentation you show above could be used for educational purposes, or as a reason for dismissal.
I do not, however, understand the sarcasm. These snippets were written by, supposedly, professional people.
I am embarrassed for them. How can they call themselves nurses? Their documentation portrays them as ignorant, and puts them at risk for lawsuits. Who would be crazy enough to defend them?
I am not sure remediation would prove beneficial to either the agency they work for or the patients they service.
Feeling pretty good about the charts I review now.

I do understand this response.  The sarcasm is a product of my sense of humor; nothing more and nothing less.  As far as who would be crazy enough to defend them, I can give you some names but you would have to remember that while an agency is rather pathetic in its performance it does not mean that everyone associated with the agency is ignorant and pathetic.

I personally have charted that Dr. Kevin DiBenedetto was at the bedside attempting to urinate.  X3.  Unsuccessful.  (The doctor did eventually intubate the patient successfully and a few hours later I was finally able to go to the bathroom.)  According to my documentation, I also gave a complete blood bath that surprisingly, the patient tolerated well.  Another time, Super Nurse here got a patient and walked with him outside the day AFTER he died.

The difference between my erroneous documentation and the stuff I posted is that somebody found these mistakes almost as soon as they were made.  My back was covered.  If I had been asked a year later about a home visit where I walked with a patient outside the day after he died, I wouldn’t have been able to legitimately and ethically correct the date.  If Medicare had discovered it, it might have been viewed as fraud.  I would hate to be questioned in a deposition about how it came to be that my patient tolerated a blood bath well.  (“I told you I was good.  Now do you believe me?”).

These charts I took screen clippings of were spread over the course of a year.  How does that happen?  How can such outrageous documentation be present in the clinical records and everyone is clueless?  I assure you that it is NOT a nursing problem.

The first thing that the respondent above wrote was, “I review charts daily for my organization”.  It is an expense to the organization that employs this nurse that is not directly revenue producing.  It is very difficult to quantify the amount of value she brings to the organization in a spreadsheet.  There is no formula that says if she does ten clinical record reviews, the agency will be ahead X number of dollars. In fact, this nurse may do a lot of work that actually identifies errors that result in lower payment to the agency.  So, it stands to reason that the organization cares about the integrity of its documentation, ethics and is sophisticated enough to recognize the value of risk reduction.  I hope they call me if they get a ZPIC letter.  I like winning.

The organization which employs the nurse is also concerned about the quality of care.   He or she did not leave a name so I don’t know what pronouns are appropriate but the organization employing this nurse has created a culture based upon the quality of care of the patients.  Even the best, most caring non-clinical person cannot set policy about patient care.  You don’t see nurses trying to handle billing and accounts payable and you shouldn’t see CFO’s making clinical decisions.

This nurse also wrote that she wasn’t sure that remediation would be beneficial to the nurses or the patients.  Medicare agreed with her.  They didn’t do anything drastic like take back the provider number.  They did something much more effective.  They stopped payment completely and now the agency is gone.

ZPIC 1 – Agency 0

Oh, by the way, if I didn’t have a sick and twisted sense of humor, I would not be able to do my job.  I would rather work at Taco Bell if I took this stuff too seriously.   But I apologize if I offended you.

7 Comments Post a comment
  1. Helen Woolf MSN, RNBC #

    I have been facilitating at an online, BSN and MSN program. These are all nurses, who have worked and supposedly documented. They are required to write papers etc. I have been doing this for about 4 years, and for all intense and purposes, there is not a nurse out there that can put two words together that sound like they have had a high school education. I am appalled. Referring to patients’ care they state, “theyre home is a mess” or something to that effect. They have no idea how to use words, when to use commas, when to use their, they’re or there. What is wrong with our nurses and probably all former students? It is our education process from day 1. They are passed on their English writing and comprehension, which, I suppose, they are forgetting once the graduate high school. These grown women and men, working as nurses, become angry with me because I mark them off on their grammar and punctuation. I say, “someone has to set them straight”! What has happened to the education in the US????

    December 2, 2011
    • Susan #

      Been doing it for 9 and you are very right in more cases than not, but not everyone.

      Part of it I think is we don’t teach grammar anymore. Much less keyboarding skills. My daughter hated me when I made her take keyboarding. By the time she was typing her thesis and working on her DVM she didn’t hate me anymore.

      December 4, 2011

      • Grammar and spelling are very important to me. I make mistakes but I assure you that nothing embarrasses me more. It is amazing to me how many people, incredibly smart people, do not write well. I have come to be okay with that because I am utterly convinced that if you don’t get by third grade, you won’t get the whole writing, spelling thing for the rest of your life. I have an extremely successful client who cannot string a sentence together in an email to save his life. Yet, one day when I was at his office, we were trying to compose a letter concerning a delicate situation. He ‘dictated’ to me what he wanted it to say. He was far more articulate than I could have been. Yet, had he written it I am quite certain that it would be a disaster.

        Writing gets me by. Whether I am writing reports for clients or communicating via email, I can assure you that I have to choose my words carefully. I also have back up support and systems. No work that I am paid for leaves the office without someone else reading it first.

        When it comes to clinical notes I don’t care about the grammar for the most part because I can’t fix that but I always wonder what the reviewers think when they see poor grammar. If the only information I ever received about the client mentioned above came from his emails, I would think he was an idiot. He is no idiot, I assure you.

        I take exception to laziness. There are 20 million or so different drugs out there. If you get to a patient’s home and you don’t know a new drug ordered, don’t just make something up or tell the patient to take as directed. LOOK IT UP!! At least try to remember what you taught on the last 32 home visits before you teach the patient to reduce clutter and provide for adequate lighting one more time. Read your last visit note if you are forgetful. I hate reading about a scheduled MD visit one week with no follow-up the next visit. It is like a mystery novel with a clue the detective misses.

        The comment below speaks to telling a nurse over and over what she is doing wrong and they still do it. She wants to weep. I am not as sentimental. I start fantasizing about large, automatic weapons that you have to purchase in some dark alley across the border in Mexico. I think that there are two issues. Maybe they don’t get it. Sometimes it isn’t enough to tell someone what they are doing wrong; you have to show them how to do it right. Just like patients, that may come from any number of teaching activities. A very effective one is to have them review other charts. It is easier to see another nurse’s errors than your own because natural defenses are down. Having a nurse come in daily for a period of time and sitting with them while they document can be effective. Recognizing improvement is very motivational when a nurse begins to improve.

        Secondly, if they are just not willing to try, then maybe they need a job where documentation is not required. I hear Taco Bell is taking applications.

        December 4, 2011
  2. Emily Gay #


    I just couldn’t help but respond to the comments from your documentation quiz! As a BSN and CLNC, we have to remember that our nurses are in the trenches taking on case loads that are large in numbers and while doing so, trying to do the best that they can. It is very easy to be a nurse behind a desk, but when we put on our “field hat” the role of nursing these days takes on a whole different meaning. As a CLNC who reviews documentation, and as a nurse, I wear both hats, and am insulted by the comment that nurses are ignorant. Having been in the nursing profession for 30+ years, my belief remains that nursing starts in the heart, not the brain. What we need to instruct our nurses on is proper documentation not only from a Medicare point of view, but also from a legal standpoint. I have had the luxury of working with new graduates, and there are some of our nursing schools who are teaching documentation that is legally incorrect. Julianne, thank you so much for bringing this most important topic to our attention, as documentation will only become more important as our future role of healthcare providers.

    December 2, 2011
    • Gail #

      Well, you know what Loretta Lynn said, “I may be ignert, but I ain’t stupid!!” And there it is. A beautiful and talented, put uneducated country girl became famous, rich, and successful. She may have been ignorant, but she surely wasn’t stupid. It’s OK to be ignorant as long as you don’t make it a habit. Ig-no-rant; 1 a: lacking knowledge or comprehension of the thing specified. Webster’s Ninth New Collegiate Dictionary. The problem is not ignorance but the lack of the desire or will to obtain needed knowledge to correct the ignorance. I am totally ignorant when it comes to all things electric. It amazes me every time I flip the switch and the light comes on. If I wanted to learn all about electricity, I am sure that I could. Nurses should want to learn all things important to their specialty, including but not limited to, proper grammar, spelling, and a professional persona. Skill and prowess with an IV, changing a dressing, or administering medications are indeed important, but it’s so much more than physical ability to perform a task. A degree is not always necessary to be well-educated; desire and passion for learning is really all that’s required. Try it. You may like it.

      December 2, 2011
  3. Gail #

    Helen, Please don’t get me started. I have nurses (RNs and LPNs) who document;
    “Done wound care on the patient no S/Sx of hyper/hypotension GERD A-Fib osteoarthritis Had no BM for 3 days gave a Fleece (sic) enema.”
    “The pt has a busted blister on the side of his left foot.”
    “Pt fell last night slipped on rug has a big goose egg on the back of her head.”
    “Elevated BP RT stress of grandkids at home (great). SN taught CG & Pt to keep pt relaxed & kids quite (sic) and for pt if need to go to bedroom & relax call SN with HA CP, nose bleeds dizzy pt states understanding.” Oh, by the way, you have one typo…”once theY graduate” and one misspelled word…intents not “intense”. 🙂 You are right, we all make misteaks…(sic)… now and then and it’s excusable. But, consistently poor communication skills (such as poor grammar and punctuation) can put a nurse in a boat-load of trouble. If they have escaped unscathed so far, they are just lucky.
    Juliene, Your sense of humor is refreshing and probably keeps you from ripping you hair out and running screaming naked into traffic. If you offended, then I am sure I would offend too. So be it. I have always gone by the philosophy of my one-time but now deceased (at age 47) employer…an OB/Gyn MD who loved life and people and music…”Life is too serious to take too seriously.” Amen and Amen.

    December 2, 2011

  4. When I audit charts it makes me want to slit my wrists. I do understand the pressures and the stress, I have been a nurse for many years. I understand the errors, the dead brain trying to express in words that which will result in a “skilled need” for our payment sources. And yet, when some people are told over and over again that they are doing something wrong – “take meds as ordered”, and still they do it, I just want to weep.

    Why? Is it on purpose? Subtle sabotage of the agency? Do they just not get it? Notes are all we have to show what we do. I know much of what we do never gets documented, but we have to prove our worth somehow. Yet I know from the care and the outcomes that these same documentation slackers are good nurses.

    December 3, 2011

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