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!

Ahneeda

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post with examples of good documentation but I can’t.  Good documentation includes too much information that should not be published on the internet.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.