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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.

Five Steps to Improved Documentation


 

Paperwork is part of the job. Next to patient care, it is the most important part of your job. Wouldn’t it be nice to see your patients and document well in time to don your pearls and cook dinner for your family? Or maybe you just want a cocktail or two while you watch the evening news. Pretty much nobody wants to stay up until midnight documenting so that they can be paid on time.

  1. Turn off the Cut and Paste function. There are some clinicians who should have a neon sign on their forehead reading, ‘I document. Therefore I clone.’ Turn it off. If you survived nursing school or have an advanced degree in therapy, it stands to reason that you can compose an original note without copying the prior note.
  2. Write plans of care that address the patient’s issues. No more. No less. If there are two or three pages of orders, the important stuff will be buried in the minutia.
  3. Read the care plan. That sounds obvious but nurses cannot read care plans if they aren’t present and in the chart. This should be a priority and nurses should refuse to see the patient if they do not have one. At the very least, a verbal report from the admitting or recertifying nurse should be given and documented. It is easy to lower the bar on this but very difficult to raise it. But we are nurses. We do difficult things and we need care plans.
  4. Payment is often in the details. If you are not in a position to document in the house, keep a pocket sized notebook with you and write vitals and what was taught.
    1. Weights
    2. Blood pressures
    3. Pain
    4. Heart rate
    5. MD visits
    6. Medications
    7. MD and hospital documentation
  5. Teach only useful information that your patient can understand. The internet has no shortage of teaching guides available from the web. Look for teaching guides that have been published by reputable organizations such as the American Diabetes Association, the CDC, the National Institute of Health and University hospitals. That way, if the information is bad, you can at least credit a reputable source. Upload this information into the computer in the patient’s electronic record. Then you can chart, ‘reviewed pages 1 – 4 of DM teaching guide and taught page 5’. And remember that teaching guides should vary according to the patient’s needs.
  6. Complete a short pre-visit checklist the day before your visit that includes calling your patient to confirm the visit, ensuring that appropriate teaching guides are uploaded and available in printed format for the patient, determining if there are additional orders since your last visit and read any documentation that another clinician submitted. This will ensure that you are able to give the best care possible to your patient.

Although going through these steps may seem like more work, it isn’t. Consider driving 15 miles to a patient’s home only to discover they had an MD appointment. If you are unprepared for teaching, you may waste your time and the patient’s. Reconstructing notes and trying to remember vital signs is a task that is slightly less pleasant than a root canal and takes time. Doing the job right the first time saves so many headaches that the manufacturer of Advil would be in jeopardy if everybody bought into the concept

Perhaps the greatest delay in documentation is finding better things to do. It requires discipline to complete quality paperwork within 24 hours of a visit. It is a habit you need if you are to be in home health longer than a week.  Believe it or not, there is an app for that. Actually, there are fifteen apps for that. Try one. Because although clean documentation that doesn’t boomerang back to you and is submitted on time gets the agency paid, the effect on your life will be even more amazing.

Work Place Violence (and free CE’s)


workplaceviolence_bannerI must say that everyone is pretty good about conducting a home safety assessment. Throw rugs are removed, lights are bright and shiny and and much of the work done by therapists is to reach the goal of the patient being able to safely navigate in the home environment. Geaux, Team!

We’re missing something. What about employee safety in the work environment? Everyday home health and hospice nurses, aides, MSW’s and social workers go into homes where they are separated from the agency and out of view of anyone who might help them. All but the most serious incidents are overlooked.

In addition to the injuries that happen regularly such as sprains, abrasions and other musculoskeletal injuries due to moving patients, these are routinely addressed in orientation and annual inservices. A risk of workplace violence also exists and recent research shows it is more prevalent than you may think.

Homecare workers (n = 1,214) reported past-year incidents of verbal aggression (50.3% of respondents), workplace aggression (26.9%), workplace violence (23.6%), sexual harassment (25.7%), and sexual aggression (12.8%). Exposure was associated with greater stress (p < .001), depression (p < .001), sleep problems (p < .001), and burnout (p < .001). Confidence in addressing workplace aggression buffered homecare workers against negative work and health outcomes.1

The CDC along with NIOSH has published an online Continuing Education course addressing workplace violence for healthcare workers. It is not specific to visiting nurses but does offer useful advice. It also offers 2.4 continuing education credit but if you want the credit, read the ‘instructions for credit on the first page. It is provided at no cost and includes short video clips, written text and discussion questions.

In taking this course, I learned that when adhering to the strict definitions of Workplace Violence, many homecare workers have experience with verbal and physical aggression. We also under report workplace violence and ‘forgive’ our patients. It may be a fact of life that nurses eat their young but it doesn’t have to be and agencies should not tolerate bullying of their employees. Regardless of the kind of workplace violence that takes place, visiting staff may suffer stress, depression, insomnia and burnout as noted in the study cited above. Without support from management, the agency’s morale will deteriorate to the point where nothing gets done.

If you know of any other resources to reduce the risk of workplace violence in the workplace, please share in the comments. Our workplace includes most zip codes in the country and all types of people. Reducing the risk of violence and supporting visiting workers can go a long way to making sure you’re agency doesn’t lose its best employees to burnout.

  1.  Hanson, G. C., Perrin, N. A., Moss, H., Laharnar, N., & Glass, N. (2015). Workplace violence against homecare workers and its relationship with workers health outcomes: a cross-sectional study. BMC Public Health, 15, 11. http://doi.org/10.1186/s12889-014-1340-7

Novus Hospice

Novus Hospice in Frisco accused of aggressively managed length of stay numbers by overdosing patients on continuous care.

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Suicide Contagion


Every time a celebrity commits suicide, we pay attention to Depression and the tragic end outcome if Depression is not treated or does not respond to treatment; at least for a little while.

I have never owned a Kate Spade purse but I liked her. Together with her husband, they created a brand that took whimsy seriously and added color to our world.

Anthony Bourdain lived the life of my dreams; travel, adventure and food. Could there be more?

Neither Kate Spade or Anthony Bourdain allowed their public personas to reflect the extent of their illness. This is understandable in terms of privacy but leaves many people shaking their heads because they can’t understand how celebrities who appear to have everything would choose to die.

Home healthcare patients are confined to their homes. Some have lost one or more spouses and may be separated from family who have moved to pursue careers. They are sick and many are in pain. Their outward presentation is that of a patient population at high risk for depression.

As it turns out, 20 percent of people over 65 are depressed and men in their 80’s have highest rate of suicide of all age groups.  Across the board, the rate of suicide is rising as funding for mental health is declining.

Suicide prevalence image

As of last week, patients are at an even greater risk for suicide due to the phenomenon of Suicide Contagion which is exactly what it sounds like.  Suicides occur in clusters almost appearing to be contagious like a virus.  In the four months after the loss of Robin Williams, the overall suicide rate increased by 10 percent. Google searches for suicide related topics increased after Netflix aired ‘13 Reasons Why’. There was a 25 percent increase in the number of calls to the National Suicide Prevention hotline in the two days following Anthony Bourdain’s death.

One reason has been attributed to journalism standards. There are journalistic guidelines for reporting suicides that nobody seems to follow. Near the top of the list is not reporting on the details of suicide.   When reporting on a suicide, the WHO also recommends including information on how to get help. Most initial reports of last week’s high profile deaths included this information – usually at the end of an article that might be missed – but as the days progressed, more attention was given to the ‘gossip’ and a few interesting conspiracy theories surrounding these stories.

But we’re not journalists so how does this pertain to nursing.  How many of your patients spend most of their waking hours tuned to the television news?  Depending on the reporter or news station, some news stories are almost like a tutorial or at best a psychological autopsy that is really none of our business.  Most nurses also have social media accounts.  Think twice before sharing or reposting a story that has sensational or dramatic headlines.

What should you do for your patients?

  • Regardless of prior diagnoses or risk factors, encourage your patient to do something other than consume the details of tragic suicides. You might investigate alternative viewing options, suggest some time outdoors, a book or a crossword.
  • Pay attention to your PHQ2 assessments. I am incredulous when reading about patients who start their day with a round of golf and end it with their chest opened with power tools due to a cardiac event. Three days later they are admitted to home healthcare and report zero days with little interest or pleasure of doing things or feeling down. A positive PHQ2 does not confirm a diagnosis of depression but it gives you a baseline and together with the physician, you can look at medication side effects, ensure the patient is able to sleep and address pain. If the patient doesn’t show improvement in two weeks, there is a strong possibility that he or she won’t participate in their plan of care to the extent that they can which will prolong healing and further treatment may be indicated.
  • If your patient is pre-loaded with a diagnosis of Depression and is on medication, take it from there. Don’t just assume it has been handled.  Teach side effects of meds, encourage socialization, educate the family, etc. Never assume that a med is going to work completely and consistently. After all, diabetic patients aren’t started on metformin and never checked again.
  • Talk about depression in the same tone that you talk about other diagnoses. Depression is seen by many from former generations as a weakness. Assure your patient that depression is an illness and is not a reflection on their character or inner strength.
  • Leave written information adjusted for the reading level and visual acuity of your patient about resources they can access if symptoms worsen. Put the information in a place that is obvious to the patient and near the phone.

Depression is not a normal part of aging. You can implement measures to improve your patient’s depression and dramatically improve the quality of their life. With mental health funding dwindling across the nation, we need to up our game.

Other Resources

Men and Depression – low literacy

Depression in the Elderly – low literacy

CDC Suicide Prevention Fact Sheet

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