Documentation Bloopers
I have an old file of documentation that I have saved especially for you. These examples are many years old and I have taken great care not to disclose the agency or individuals responsible for this documentation. Note that these are not my regular clients and I was hired to read the charts after the agency was called upon to submit charts for a ZPIC. Also, the agencies from which this documentation originated are no longer with us and many of the nurses no longer have licenses. They were not victims of an overarching regulatory body. They were victims of themselves.
You may have questions about the clinicians who wrote these notes as I do. More importantly, where were the checks and balances that ensured that the care was delivered to the patients was sound and documented appropriately? I could comment and question indefinitely, but you’ll probably see the same thing.
1. SN instruction given on measures to control hypertension check your blood sugar at least once a day and exercise to lower your blood sugar unless you are sick or have a blood sugar over 240 mg to prevent further complications.
The instruction to control hypertension may include checking blood sugars if the patient has diabetes. The patient did not. Exercising once a day may be out of range for most home health patients.
2. SN assessed all body systems. VSS. Pt c/o weakness, states I hurt all over. No meds taken for pain. SN instructed on factors that increase risk for HTN: high na+ intake, high cholesterol intake, obesity & sedentary life-style. Pt verbalized understanding.
This nurse at least tried to follow the care plan. Could this be the result of a manager demanding that nurses follow care plans?
3. Instructed if you have any problems with this med go back to ER because we don’t have an order from Dr.
Really? I wonder if the Doctor had a phone number the nurse could use.
4. Vitamin A and D ointment topical 1 PO for 7 days.
Sadly, this was repeated over 7 episodes. Sometimes, it is easy to determine who is reconciling meds on a per visit or per episode basis.
5. Pt awake and alert but forgetful sitting up in recliner with legs hanging. Edema noted to BLE. Slow ambulation assessed. SN instructed pt to be aware of possible complications of osteoarthritis; Gastrointestinal bleed and stress ulcers.
At first I thought that one little word was missing as in ‘…. be aware of possible complications of osteoarthritis meds….’ A closer look at the chart showed no NSAIDs or arthritis meds. Still, maybe she took ibuprofen by the boatload and the nurse didn’t deem it important to add over-the-counter meds.
6. SN assessed all body systems. VSS. Denies any discomforts at this time. SN instructed in possible complications of HTN: kidney failure, stroke & heart disease.
This patient was on dialysis and had coronary bypass surgery but apparently the nurse was directed to teach only from agency approved teaching guides. Note that there was no action for the patient to take. The nurse went into the home and told the patient all the ways he could die and then left.
7. SN assessed all body systems. VSS. SN instructed patient if any problems occur to call 911 or go to ER. Patient verbalized understanding.
Why even bother to send a nurse between ER visits?
8. Pt is very anxious. His hands shake – stated he has got to see paleontologist[i] next week. Client exhibits severe knowledge deficit regarding his disease process and TX regimen. He is very forgetful and depends heavily on caregiver to assist with his care. He is highly potential for acute complications of his disease process. SN to monitor closely and intervene as needed.
Besides the amusement factor of a patient visiting a paleontologist, this was found on four care plan summaries in a row. With spell check and predictive text, etc., errors happen. They are corrected when in an agency with checks and balances.
These agencies have other things in common. Most are making less money than if they hired a couple of extra nurses and employed managers who did not overload their nurses. Their billing was perpetually late and mistakes in billing were not addressed. There was a culture of blame instead of support and compliance. They are owned by people blinded by greed.
I like making money. I’m sure that you do, too. We are so lucky to earn our living in an industry that allows elderly patients to remain in their homes and our take-home pay is so much more than a check. Meanwhile, remember that the real reason for documenting is so that the nurses, therapists and physicians who take care of the patient after you do have access to a true and complete account of the care the patient has received.
Oh, and a Lamborghini has never made anyone’s life better unless they were an Italian race car driver.
[i] I hope nobody was insulted because I linked to the definition of ‘paleontologist’ but I had to look it up the first time I saw it just to make sure I wasn’t slipped LSD. The definition did not reassure me. At all.
I always liked the documentation for 4+ pedal pulses on the bilateral amputee. Over and over and over. When questioned as to why, the response nearly made me faint….
“It’s just a habit. ” Really? Also, I HATE a “pussy wound.” 😳
It makes you kind of wonder what other habits that nurse has; smoking crack?
I had a patient with a glass eye whose doctor’s visit notes always included bilateral PERLLA. Really, doctor?
Have you seen the prices of Medical devices? I would expect the pupils to be reactive and take photos and change color to coordinate with your fashion choices!
Show of hands – who else breathed a sigh of relief that none of their rookie mistakes showed up in this blog? 😉
I have unfortunately had to document, “Instructed to call 911 and go to ER for exacerbation of disease process including tight feeling when breathing, wheezing, shortness of breath,” I’m sure we all have. Just remember to chart what else you ALSO did, so the nice lady at the deposition knows you did your best to fix this: “Phoned pharmacy for refill of albuterol, spoke with pharmacist Jane Doe; they have no refills on order. Pharmacist says she will fax authorization to Dr. Smith and deliver albuterol by same day delivery when filled. Verified MD fax and phone with pharmacist. Phoned MD office x2, was sent to voicemail by automated system x2. Left message on voicemail option #4 that patient is out of albuterol and Doe Pharmacy is faxing authorization request per pharmacist Jane Doe, phone number yackety blah…”
Cause yes, the doctor has a phone. Doesn’t mean someone always answers it.
‘The nice lady at the deposition’ made me laugh out loud. And as you suggested with your example, good documentation can be tedious at times but as a fan of ‘Orange is the New Black’, I gather the laundry detail is also tedious interrupted only by moments of terror if you are in the dryer when someone turns it on.
These are gems!!! I have seen quite a a few in my time. Does anyone ever read the notes???
That’s debatable. With computers it is tempting to read reports that indicate a note is complete. And sometimes it is hard to read every note when a case manager is out and the nurse with 60 outstanding notes decides to turn them in that day and billing is advising anyone who will listen that they can’t bill. But these are not isolated notes. When an error is repeated numerous times, it shows a complete breakdown of processes.