Skip to content

Posts tagged ‘Home Health Nursing’

Dec 1

7 Comments

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post with examples of good documentation but I can’t.  Good documentation includes too much information that should not be published on the internet.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

Nov 28

2 Comments

Short and Sweet Documentation Quiz

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.

After reading charts from agencies chosen for ZPIC audits, I decided it would be easier to teach you how NOT to document.  Please understand that if you document like the examples in our little documentation quiz that I cannot help you.  The best lawyer in the world probably cant even help you except to maybe reduce your prison term.

Take the quiz.  I can’t wait to see your answers.

Nov 16

2 Comments

Diabetes Teaching

If you live in Colorado, this post may not interest you very much.  You seem to be

very thin people with low A1c’s.  You are to be envied.  The rest of you, please take a look at the maps to the right of your screen.  The first one shows the prevalence of diabetes in the US and the second one shows the prevalence of obesity.  Both maps are from the CDC Data and Trends web page that is invaluable to information junkies.

What occurs to me because I read charts pretty much

Diabetes in the US

Obesity in the US

every day of my life is that I rarely see any teaching about weight loss.  Every once in a while I will see, ‘maintain ideal weight’ as teaching in a list of 6 other things copied directly out of a care plan but mostly diabetic diet teaching consists of ‘avoiding concentrated sweets’ – whatever that means.

When we talk about diet to any patient on a therapeutic diet, most of the emphasis seems to be on what the patient cannot eat.  Many patients have multiple dietary restrictions and frankly if a nurse came to my house four visits in a row and kept adding things to the ‘do not eat list’, I assure you that the agency sending the nurse would have yet another LUPA.

Part of planning care is to gather the tools you will need.  Every nurse who has ever started an IV in the hospital and didn’t have a Tegaderm with which to secure the line knows that luck favors the prepared and patients do get tired of you holding their IV in place until someone reluctantly brings you the supplies you forgot.

In home health, we just wing it.  We teach the patient to avoid concentrated sweets and that canned foods are high in sodium.  Over and over and over again.  And for this, we charge money.  Yes, indeed.  Life does not get sweeter except that our patients don’t get better.

Consider the following resources when teaching diets to diabetics or any patient.

Choose my plate is an interactive tool where height and weight are entered into the boxes and a dietary plan is generated.  It has multiple supplemental tools that assist in helping the patient choose foods to eat instead of being told what they cannot eat.

The National Institute on Aging has a great guide for healthy eating for seniors.  The individual chapters are printable so you can take what you need for your specific patient.  It has information on how to shop on a budget, nutrient dense food, how much to eat, one chapter on foods that should be limited and how to enjoy meals.  This is detailed teaching that goes far beyond ‘avoid concentrated sweets’.

Diabetic Super Foods is a great one visit teaching tool to use with a patient who is non-compliant with his diet.  It may be easier to get the patient to agree to eat one of the listed foods every day instead of repeating the ‘avoid concentrated sweets’ routine that is apparently not working.

Also from the American Diabetic Association is a tool that teaches diabetics how to eat sugar.

All of these tools have a ‘print’ button on the page itself.  By using that button (usually at the top right), you can avoid printing pages and pages of ads, etc.

The purpose of teaching is not to have the patient ‘verbalize understanding’.  The purpose is help the patient reach their goals.  These teaching guides and others are designed to change behaviors so that the patient can enjoy their life.  In order to make it meaningful for the patient, find out what foods he or she likes and then work them into their diet.  Find out who does the cooking for them and what kind of budget they have for food.  If the patient is not in control of what foods are served in the house, involve the caregiver(s). Teach that diabetes often runs in families and that weight loss may prevent or delay the onset diabetes as well as high blood pressure, joint disease, heart disease and some cancers.

Reinforcement of teaching is important as well.  This is not done by teaching the same thing every visit, however.  Rather, teaching can be reinforced by weighing the patient weekly and making a chart for the patient to see his or her progress.  Point out when blood sugars begin drifting down.  Bring a new recipe for the family members to try each week.

If there is no progress towards goals, step it up a notch.  Before your visit, call the patient and ask him or her to tell you what they ate for the prior 24 hours.  Enter the data into one of the many online programs that analyze calories and nutrients.  Show the patient cold hard data about their diet.

If you are so lucky, and it would be rare here in the South, there may be a computer literate family member you can engage in assisting the patient with monitoring his or her food intake.  If not, food diaries are excellent tools.  You can schedule a phone call to remind the patient to write down his food every morning until it becomes a habit.  You can also possibly schedule a recurring email if there is someone in the house who checks email.

If you got anything out of tonight’s post, I hope it is that ‘avoid concentrated sweets’ does not cut it as diet teaching.  I’m still not sure what that means.

If you know of any other resources in the public domain for teaching, please share them here so we can all benefit.  Remember to review any tool to ensure that it suitable for your patient.  If it isn’t, find another one or make it suitable.  Food should be fun.  It is an important part of our culture.  Families come together over meals and histories are shared over desert and coffee.  Food should not be a religion or a stressful event.

If you live in the South, our food is killing us, apparently.  The rest of the country, except Colorado, is not far behind.

Oh, and do not go there.  Sending your patients to Colorado is not an appropriate nursing intervention on a care plan.

Nov 9

7 Comments

Tracy. Arturo. Elham.

Like most people with the internet I read Mona Simpson’s eulogy for her brother, Steve Jobs.  An author, Ms. Simpson has a way of delivering the truth and celebrating those qualities that made her brother insanely creative and well, difficult at the same time.   The entire eulogy can be found here.   As a nurse, this line registered the loudest.

“Even ill, his taste, his discrimination and his judgment held. He went through 67 nurses before finding kindred spirits and then he completely trusted the three who stayed with him to the end. Tracy. Arturo. Elham.” 

So maybe 4 percent of the nurses who passed through Steve Jobs life in his last months met his standards?  Wow.

My first thought was that Steve Jobs must have been the patient from hell.   We’ve all had them and there is probably an element of truth in that statement.   He was known for being demanding of his employees and very passionate about his work.  But we’ve all taken care of passionate and demanding patients and didn’t get replaced.  It’s just our burden as nurses to understand that some patients are put on earth to make us question career decisions and reaffirm our dedication to those patients who deserve us.  Let me emphasize that this was my first thought but not my last on the Steve Jobs as a patient theme.

Steve Jobs had advantages that our typical patient does not have.  He was very curious about a lot of things including electronic gadgets and from I read from his sister, tea roses.  I have no doubt that he knew more about his rare form of pancreatic cancer than 99 percent of nurses on the planet.  He probably memorized every side effect of every drug and had a spreadsheet for lab results.  Steve Jobs, unlike the vast majority of our patients knew who was competent and who did not adequately prepare to take care of him.

The second thing that Mr. Jobs had was money.  Our patients never cut us a check.  They never the see the huge sums of money that go into providing them the care they receive from home health agencies and all associated providers.  As a result, the care seems to be ‘free’ to our patients and therefore, they expect a little less.  Or they never question their doctor’s referral to your agency and so they believe that they really don’t have a choice.  Sadly, sick people without financial resources or insurance often do not receive our care.

So then I asked myself how long I would have made as Steve Jobs’ nurse.  Hmmm……  I am not sure they make stopwatches that measure such tiny increments of time.  Being that I am an information junkie, I might have gotten the pathophysiology and medications right but when it comes to patient care, I do so much work with Medicare and other payors that I often refer to myself as a once removed government employee paid by the hour.  I’m afraid I would have to insist on doing things my way to meet ‘evidence based practice’.

Steve Jobs had his own ideas about everything and I am quite certain that he had some ideas about how he wanted to be treated that differed from traditional nursing care and evidence based practice.  I wonder how many of the 96 percent who didn’t make the cut tried to impose their will upon a terminal man who was quite certain about what he wanted in life and as it turns out, death.

Were the 96 percent of rejected nurses in awe of the fact that they were taking care of one of the most creative geniuses in the world; the Steve Jobs?  Or did they see just another patient?  I suspect that Tracy, Arturo and Elham simply saw a father and a husband spending some time with his family before he was permanently deleted from this planet’s hard drive.

I will never find out if I could make the cut.  There are no openings in the Eternal Care Unit.  But I do know that my attitudes about direct patient care are not the same as they were when I graduated Nursing School and went to work in the Intensive Care Units.

Do you have what it takes to be in the elite four percentile?  If you had been Steve Jobs’ nurse would you have done what it took to be competent in helping him make decisions about his care?  Do you make it a point to really know who your patients are and what they want?

We do not work for the feds, y’all.  Medicare and other federal agencies have no clue about what we do.  We are not employees of large insurance companies.  You don’t even work for the agency that signs your check.

You work for the patient and with the patient at whatever level they are when they come to you.

Steve Jobs was not a perfect man but he changed the world because of his passion and his will.  He did it in beautiful ways that are fun to play with.  I ordered an iPad before they were released and I have only been without it for one night.  I was very close to checking myself into detox before morning.

Your patients also changed the world.  They fought in wars and raised families and built communities.  They have taught school, doctored sick people, worked as double shifts during harvest until they were so tired they felt it in their bones.  Some of them did very little with their lives because they just didn’t possess the gifts required but that doesn’t mean they didn’t mean as much to someone as Steve Jobs meant to us.

I’m sure it was an honor to take care of Steve Jobs just like it is an honor to take care of all of our patients.  Whether we like our patients or don’t, that’s what we do.  We take care of sick people in their homes so they can be with their loved ones.

Nobody was more deserving of excellent nursing care than Steve Jobs.  Nobody is less deserving of excellent care either.

 

That’s all.  Just talk amongst yourselves while I get back to work.

Oct 31

2 Comments

Father and Son

Goal Accomplished!

Since our first day of clinicals, we were taught about setting goals.  What is it that we want for the patient?  Do we want him to be free from injuries related to falls?  Maybe getting his A1C below 7 or his blood pressure to be below 150/90 is a desirable goal for a patient?  What about lab work and medications?  Does it make sense to set a goal concerning medication compliance or a serum potassium between 3.8 and 4.5 if a patient takes diuretics?

All of those goals meet the criteria we were taught as young nurses.  They are measurable, obtainable, and realistic.  They could all be achieved inside of an episode or throughout the episode, etc.  They would meet with approval from a surveyor.

The picture above is my friend, Bill and his dad.  At first glance it may seem like a picture of a patient with a caring family member.  It is so much more than that.

The gentleman to the right was Bill’s father long before he was a patient.  He is retired from the military.  He has had a long life filled with stories of success and failure, love and loss, happiness and sadness just like the rest of us.  I don’t think it would surprise him to find out that he is approaching the end of his life.  And that man – not the patient – could probably give a flying flip about his A1c or serum potassium level.

If you were to ask him what his goals were upon admission, he might tell you that he wants to spend more time with Bill.  Or if he is in pain, he would like some relief from the pain that causes him to be emotionally unavailable for visits with his loved ones.  He might have a goal of going to a relative’s wedding or just going to the store soon.  He may even have the unreasonable goal of running a marathon soon.

If you begin your relationship with your patient by finding out what they hope they to obtain by being your patient, you will be given the most powerful tool you can have in accomplishing the more traditional nursing goals.  Regardless of whether or not the goals are reasonable is really not our business.  We start where the patient is and we don’t mainline reality into him like a lethal injection.  If he wants to spend more time with less pain so he can visit his son, then we can use that to encourage him to participate in therapy.  If he wants to run a marathon, ask him what that would be like.   It could be that he has not had the time to mourn the loss of his younger self and your patience and willingness to listen will help him come to the conclusion that there may be a better way to live that doesn’t include running a marathon.

I am the very same person who swam on the swim team when I was four and the same teen aged girl who has been lost in more continents that most people travel to in a lifetime.  I am the one who married a man I later divorced.  That was me showing up at nursing school on the first day in a white skirt with coffee spilled all over it.

Maybe if you think back when you were 5 or 14 or 22, you will realize that it was you all along.

I cannot think of a better way to care for a patient with respect and dignity than by finding out who they have been all along and work with them to accomplish their goals. They are grown-ups just like us.  We get to determine what is best for us just as the men and women who honor us with the privilege of taking care of them.

And so on…..

 

« Older Entries
Newer Entries »