Tonight, i was trying to read nursing notes re functional status as received request from PCP for PT eval for power scooter. I pulled up electronic note from 7/16: blank except VS. 7/6 note: blank ---wound care note pulled over:blank
Note from 6/27 showed hundreds of maggots in new RLE wound, amb w walker, RNcalled doctor and now using Unna Boot on BLE.
.....went back further, 2 multipurpose notes from 6/26 + 6/25 shed some light on needing paratransit and that RN went with pt to appointments with wound specialist.......6/22 note BLANK!!!
Went to OASIS from begining of month found info I needed: no shower/bathing area, rundown apt, pt unable to read, unable to bend down reach legs to change socks etc.
Left VM for branch manager re my findings.
a. RN/LPN responsible for their documentation, not you. No need for you to co-sign notes.
b.You ARE responsbile for hauling staff member in to deliver said missing notes.
BON does not get involved in employment disputes....that would be labor board. Look up your states definition of abandoment: involves "PATIENTabandoment", not employer.
I feel your pain as had similar situation last job, small agency. DON so "desperate" for staff, as long as patient seen, put up with late documentation....got to be STAFF running the show, instead managment.
Learned I COULD NOT hold paycheck since "work performed" , but COULD tell staff member they had to bring documentation into office and meet with me prior to receiving paycheck. 2 sessions of "expectations" led 2 staff to fall into place; one resigned.
When I came to present agency, they had similar situation in one office and they learned hard billing lesson: YOU CANNOT AFFORD employee like this. Chart got pulled by state---entire day spent in office by RN to get incomplete notes filled out.
Can't bill if no paperwork in chart so really paying out salary they can't recoup.
Polish up that resume...