3 Errors

I’ve been reviewing charts all week and the same errors keep showing up over and over again.  I know the nurses doing the charting and they are not as dimwitted as they may seem on paper.  In fact, I would wager a bet that the only nurses who have never made at least one of these errors has only a passing acquaintance with the truth.

Charting Bilateral Pedal Pulses on an Amputee

The same nurses who did this also charted on the surgical wound, the therapy the patient was receiving and otherwise did an excellent job of documenting.  So, why are they charting about pedal pulses on an amputee?  Because they are used to checking the box that says a patient has bilateral pulses. The same thing happens in M1030 which asks about therapies the patient is receiving at home and when they overlook an Ostomy in the OASIS questions.  My theory is that if you give a nurse a check box, it will be checked.

Charting Tip

When a patient does not meet the response you typically chart greater than 90 percent of the time, mark it when  you notice it.  Even if you do not have time to complete the entire document, respond to those questions that you may answer incorrectly at a later time out of habit.  Outsmart yourself so you don’t end up trying to explain to some board of nursing how you were able to find a pedal pulse in some other part of the body.

Underscoring Functional Limitations

Look at the question about ‘locomotion’.  Response 2 reads: 

Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.

This response is usually selected when a patient requires a walker and it may be correct but keep reading.  If the patient requires human supervision or assistance to negotiate stairs or steps or uneven surfaces, the correct response is 2.  This is true even of patients who do not require a walker.

Charting Tip

Mentally break this question in two. 

• Does the patient need a two handed device? 
• Can they negotiate stairs and uneven surfaces without human assistance or supervision?

Transferring

Most people think of transferring as moving from one place to the other.  In general terms, that’s close but OASIS gives us a very complicated and lengthy definition of transferring.  Here it is step by step (there should be an app for this one).

• Begin with the patient in a supine position (laid out flat on their back)
• The patient then gets to a position sitting on the side of the bed.  The methodology must be chosen by the patient  because there is an uncharacteristic lack of instructions in the manual.
• The patient then stands and pivots. (I had entire tennis lessons which focused on pivoting.  If your patient is a retired tennis pro you might be in luck).
• Then the patient sits.

But Wait!  That’s not all.

• The patient must now be able to stand again
• Pivot
• Sit on the side of the bed
• Somehow get flat on his back again.

Could there possibly be more to it than this?  Absolutely.  There are some patients who do not have a place to sit next to their bed.  Their instructions are even lengthier. 

• Begin with the patient laid out flat again
• The patient then gets to a position sitting on the side of the bed.
• The patient then stands and pivots.
• The patient safely proceeds to the place where he or she normally sits.  This may be the kitchen or the porch or the toilet.  The destination is not defined but I’m going to out on a limb and tell you that it does mean a seated position on the floor because they could not support their weight.
• Then the patient sits.  I suspect that there may be a little pivoting involved here as well but the directions are not clear. 
• The patient must now be able to stand again
• The patient makes his or her way back to the bedroom as the return trip begins
• Once again they pivot (Group and Individual Pivoting lessons are available from HCS)
• Sit on the side of the bed
• Somehow get flat on his back again.

Here’s the fun part.  If your patient typically gets up in the morning and goes outside on the porch to enjoy his coffee but requires help to make the distance, you can greatly improve your outcomes by….  wait for it…  putting a chair next to his bed.  There are some patients who because of shortness of breath, weakness from a recent injury or pain, just need to sit for a few minutes before continuing their journey to the great outdoors or wherever they sit.  Not only will your outcomes improve but a patient who previously had to wait on someone to help them get up is no longer trapped in the bed until someone has the time to get to them. 

What’s more, if you recall that the definition of the day in question refers to the 24 hours prior to and including the visit, you can still improve outcomes even if you put the chair in place on admit. 

Charting Tip

Print the list and keep it with you.   It is rather complicated.

That’s all for today folks but there is sadly more where that came from.  If you have never made any of these errors, it is probable that nobody is reviewing assessments at your agency.  One of the best investments is a data scrubbing program.  My personal favorite is Episode Master although I am angling to have the name changed to Episode Mistress.

Look for more next week.