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Posts from the ‘Documentation’ Category

Feb 18

17 Comments

Work with Me, Folks!!!

deniedFor the past several months, I have been arguing with pretty much every payor source for home health there is trying to get clients paid.  After working with dozens of clients in multiple states, I am fairly confident in stating that some of you simply do not want to be paid.  If you did, you would give me and other consultants and lawyers something with which to work.  Just to be clear, I cannot work with:

  1. ‘Take meds exactly as ordered’.  (variant:  take meds at the same time each day.)   It does not require the skills of a licensed nurse to tell the patient to take meds exactly as ordered. The general rule of thumb is that if you can learn it on Oprah, it probably isn’t skilled.
  2. Duplicate medications.  Alone, duplicate medications place a patient at high risk for adverse events.  Combined with number 1, it shows anyone who cares to read that the patient should not take meds exactly as ordered.
  3. I read this in a clinical record:  I noticed the patient had enough money to buy cigarettes, but claims she can’t afford her medical supplies.  Work with me people!  You don’t get paid for your personal judgment.  The patient was at 77 percent of the poverty level. Refer to evidence based practice when you feel tempted to commit to legal documentation your personal disapproval.
  4. Prior to charting edema on a lower extremity, please ensure that the extremity is present.  I promise that if you have check boxes for right and left pedal edema and you pull all your patients who have less than two lower extremities, you will find phantom edema.  The same applies to diabetic foot teaching, pedal pulses, etc.
  5. It is not enough for a physician to document that a patient has a diagnosis.  You must also know what the diagnosis is and how to provide nursing care for the condition.  I just read an admit for a patient who was referred with Pickwickian Syndrome which was named for a very round faced portly character in the first novel written by Charles Dickens.  Because Mr. Pickwick was known largely for his girth, the condition has been renamed  ‘Obesity Hypoventilation Syndrome.  There were no orders for diets or attention to respiratory status.  I  don’t think the nurse looked up Pickwickian, do you?
  6. Diabetes Type I and II are not interchangeable.  Work with me, folks.  These older names for diabetes confused a lot of people so they have changed to simply Type I and Type II.  Type I diabetes accounts for less than 5 percent of diabetes in the elderly.  What on earth are y’all gonna do when when they recognize diabetes 1.5 as a separate diagnosis? (For now, just code as 250.00.)
  7. MD Awareness Month.  It must be MD Awareness Month because every day I read about an MD who is aware.  It goes something like this.  ‘Pt’s blood pressure is 190/100.  Patient has not taken medications.  MD aware.’  I believe that is a convoluted way of stating that you didn’t call the physician as warranted by the MD stated parameters.
  8. Someone named Pt/Cg is wandering through the homes of all home health care patients in the country.  Typically this occurs in computerized documentation that has not been edited correctly.  It makes less than no sense that you taught pt/cg in an Assisted Living Facility that Alzheimer’s is a progressive neurological disease which results in mental deterioration and eventually death.  Which caregiver did  you teach?
  9. Notifying the caregiver is a bad idea.  Imagine if you had an INR come back high and you notified the caregiver to hold the Coumadin and documented that you did so.  What if the patient had multiple caregivers and none of them held the coumadin?  What if the patient had a bleed into their brain and none of the caregivers remember the conversation and you didn’t write down a name.  Think that’s over the top?  It is.  But it happened to a client a year or so ago.  Caregivers have names for a reason.  Use them.
  10. Repetitive teaching.  The second most common reason for denial is that the documentation does not meet the standards for reasonable and necessary care.  Teaching is the most frequently provided skill in home health.  You with me?   So, in order to be paid for your services, you must teach original material or have a reason for re-teaching.  It is unreasonable to teach diabetic diet, foot care, skin care and insulin injections in a single visit.  Don’t chart that you did.  Use teaching guides.  Your patient is elderly, in pain, has poor vision, intermittent confusion, and takes drugs that impair mentation.  That might be something to keep in mind. Take your time.  Teach at the pace the patient learns and document what you did.

So, maybe I am a little frustrated this weekend but I love my job and I love home health and I take it a little personally when payor sources deny claim after claim sending the message to my clients and colleagues that what we do is not worth getting paid.

Jan 22

11 Comments

When Outcomes aren’t Good Enough

nevada-nursing-licenseSo, I have looked at charts for close to ten different agencies in the past month or so for various and sundry reasons.  Two stood out for me in a way you should think about if you give me a minute.

Both charts involved psychiatric patients living in a congregate living situation with paid caregivers.  They lived in different states and the living situations were different but the similarities are there, nonetheless which is why the second chart caught my attention.

In both instances, there was a ten day gap between the last visit and the time the patient went to the hospital and yet the schedules called for weekly visits.  There were indications that it was not safe to push the visit back and possibly even a PRN visit should have been made.  Both agencies – completely unrelated – had a policy that supervisors should be notified of missed visits and neither nurse followed the policy.

One nurse will stand before the board in defense of a nursing license and the other one will be scolded by yours truly.

The difference is not that one nurse took better care of the patient or that the patient’s condition was any better in one patient than in the other.  The difference was dumb luck.

One patient died from a subdural hematoma.  The other was treated and went back to the facility.  The questions I have are:

  • Did the nurses in each instance visit patients according to when it is convenient for them?
  • If they were employed at a hospital, would they work whichever shift they chose?
  • If a patient really doesn’t need to be seen but once every ten days or so, why not schedule the patient for every ten days?
  • Could either nurse have picked up on something that may have prevented the hospitalizations?

Honestly, I don’t know.  In fact, I sort of doubt it but who knows?  And I am not the only one asking these questions.

In 15 years of of ICU work, I saw a lot of patients die.  It never, ever felt right when a full code patient died on my watch.  The sleepless nights, the endless record reviews, the self doubt all take a toll.  After a while it got better because the brutal questions I asked myself are worse than any a malpractice attorney could ask.  And honestly, not all of the answers were in my favor.  I have made pretty much every mistake there is to make but luckily, nobody died because of them.

The nurse whose patient died will have a lot of questions that will never be answered because an assessment wasn’t made for ten days prior to the hospitalization.  My deepest sympathies lie with that nurse.

What can you take away from this?  Both nurses are guilty of exactly the same thing.   Both put off a visit until later in the week, neither one called a supervisor and the polices of both agencies were ignored. Each situation had a radically different outcome which was likely beyond their control.  Whether or not they saw their patients or notified their supervisor when they did not see the patients was clearly within their control.

Don’t be the subject of a future post.  Follow your schedule.   It is not a suggestion or a recommendation. It is what is expected of you from your patients, your employer and your state board of nursing.

Sep 3

6 Comments

Getting Paid Part 2

Do the Right Thing

This isn’t some super moralizing appeal to your conscience to stop forging signatures or lying about visits you didn’t make.  Those kinds of people do not come here for news and information.  This is more of an appeal to nurses and clinicians to follow orders.

In the past several weeks, I have read many instances of nurses charting about why they did not do the right thing.

One of the most frequent excuses for a weight that is out of range and the nurse writes in parentheses that she used a different scale.  What does that tell you?  Here’s what it tells me:

  1. She does not know what the patient should weigh
  2. She has no idea if the patient is better or worse than before
  3. She did NOT follow orders
  4. She may be costing the agency money by setting her employer up for denials

I read a note last week that state the patient’s blood sugar was 370 but the son had only just now given insulin.   There was a note that the patient ate breakfast but no MD notification.  I suspect the patient eats breakfast regularly.  The question is whether or not the son is always able to give insulin timely.  If not, maybe a different kind of insulin would be better for the patient.

I have read may notes where the blood pressure exceeded either the MD parameters or just common safe practices and the nurse charts that the patient hasn’t had their medications yet.

In other words, nurses are spending time explaining away why they did not follow the care plan when they should be notifying the MD.  Maybe the blood pressure is extremely high every morning before medication. It certainly is more convenient if the patient strokes out in the morning but that is not a reason to let a patient’s pressure pound against their arterial walls every morning.

In order to get paid you must do the right thing.  If you do not communicate with the physician and if the care plan does not change, your patient is no longer eligible for services.  Explaining why YOU didn’t follow orders is not a billable skill.

Again, here is the language that I read repeatedly when appealing denials:

The records provided do not support that the skilled nursing services were reasonable and necessary for the treatment of an illness or injury. During the last certification period, there were no exacerbations, injuries or new diagnoses that would require continued skilled services.

Any questions?

Remember, answering to us is a lot more fun than answering to Palmetto or the Zone when you get ADRs.  And if you do get ADRs after reading this, I respectfully reserve the right to say, ‘I told you so’.

Jun 2

I Love My Job

I love my job. By nature I am curious. Opening a clinical record and reading about the history of patient and the interactions between patient and nurse satisfies my urge to be nosey.

Sometimes, however, I feel as though I am being punished. Impeccable charting directly from a teaching manual can bore a person to tears. Consider the following two examples of charting about an elderly gentleman with lung cancer, completely in denial and usually intoxicated.

  1. Patient remains non-compliant with medication routine exhibiting drug seeking behavior. Notified MD. No new orders.
  2. PRN visit for complaints of anorexia. Patient states to nurse, “I called you because I can’t eat. Now you are asking me why I can’t eat. Y’all are F***ing crazy! Tell that doctor I ain’t going back until I get my pills.”

While the first note is completely accurate it really doesn’t paint a picture of the patient.

The second example tells me a whole lot more. The patient uses colorful language to be sure. The one quote tells me that he may be extremely difficult to teach. I know that it will be challenging to get this patient to buy into compliance. In other words, ‘I get the picture’. And that picture comes more accurately from the patient’s own words than anything a nurse will ever learn out of a book.

In another agency, I was reading the visit note from a nurse had gone to visit a patient in an assisted living community. The opening sentence in the note explained that the patient was complaining because the green beans at lunch were not cooked the way she preferred.

Consider how much information is in that one sentence. The patient is complaining about vegetables. Patients who are in serious pain or have no appetite due to illness usually don’t care about green beans. And this patient is not apathetic, a common symptom of depression. She really did care about her green beans. And it is apparent that this patient remembered what she ate and how it was prepared so short term memory is intact. Again, the nurse has painted a picture I can see and understand.

Compare that to, “Patient denies pain or discomfort. Reports lunch was eaten prior to nurse arrival.”

In our efforts to be professional, concise and ‘appropriate’, we often forget the real purpose of clinical documentation. Effective communication between care providers enhances the quality of care given to patients. When reading the examples above, I know I am better able to pick up care following the more colorful examples than the ones that read like a nursing text book.

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