chart auditing

[jonear2, RN]

Hi everyone!

I am still very new so I was wondering what you all thought about this:

Or hospital got a few dings when JCAHO came out a few months back. Most of the dings were on documentation and incomplete IPER (interdisciplinary education record), admission database, and home med reconciliation forms. The problem I am having is that the administration's idea to fix the problem of this poor documentation is to have each nurse audit an entire chart per shift and fix whatever errors there are with the IPER, med rec, and database forms. I am so stressed about this because I am still developing my time management skills and I am doing the best I can to get all my patient care and documentation done, much less actually sit down and go through a chart. There is a form that we have to complete with each audit- we have to make sure each MAR is signed, that every entry on the nursing notes is legible, on and on. Is this really part of my job? Are any of you having to do the same thing? Does it seem right that in order to fix noncompliance with paperwork we have added more paperwork? And if I audit a chart one day and miss something can I be held resposible for that? I dont know.

Any thoughts on this would be appreciated

[P_RN, ADN, RN]

I disagree with the part of this that says "fix what's wrong." Audits are pretty hard to do when there are so many different places to document stuff. But you should NEVER chart/late chart things you did not do. That's just wrong.

You can audit, call attenton to or flag the omission and have the actual person do a late charting etc. But DON'T start your career by charting that which you did not do. That's lying and not OK.

[dorimar, BSN, RN]

We had this very problem where i work. They were requiring 3 chart audits per month for each of us. I am sorry, but it takes all my time to take care of the patients and to Document all the increasing crap they want us to document, that i rarely have time for lunch or even bathroom breaks. I believe it is management's job to audit those charts, and when and if they find problems, i have no problem with them letting me know. But, I am not going to do their job as well as mine. I was appalled that they were giving us MORE PAPER WORK to prove we were doing the PAPER WORK. I did let them know this and they quit asking me to audit charts. Don't know if you'll have such luck, but i think it is a ridiculous expectaton and acutally takes time away for the acutal documentation & care they want you to accomplish (and agian it is THEIR JOB).

[millkay]

I am not going to do their job as well as mine. I was appalled that they were giving us MORE PAPER WORK to prove we were doing the PAPER WORK. I did let them know this and they quit asking me to audit charts.

I to you Dorimar for finding a way to get out of doing those audits. I also worked in a unit where we were required to do audits, one per month. We filled out a sheet on things that we found that were not up to par and turned it in to the supervisor. One per shift sounds like major overload when you are already busy enough with patient care. For me it was a great learning experience. I learned where we (myself included) were dropping the ball and needing to improve. Granted I didn't always find time in the course of a month to get one done. It could potentially be a good learning tool, if nothing else positive can be said. :doh: However, I fully agree that going back and fixing other people's shortfalls, ie charting is Bad and boarders on fraud. Please tell me you have not beeen asked to do this! This definitely needs to be addressed with the powers that be in your institution, i.e. chain of command. I say with caution: it should not hurt to speak up for yourself.

[CritterLover, BSN, RN]

it depends on what is meant by "fix the mistakes." to go in and chart stuff that hadn't been charted (say, filling in the gaps on a flow sheet) is unacceptable. but, if say the chart audit revealed that part of the admission history wasn't complete, it can/should be completed (with the correct date/time of course). or say there still wasn't a copy of the patient's living will on the chart. that could be requested. if a certain necessary education topic hadn't been charted on, that education could be done and charted. so if that is what they mean by fixing the mistakes, it is ok.

that being said.....i am very much against staff nurses doing chart audits. why? in my view, it is like having the fox guard the chicken coop. you end up needing to have someone audit the audits to be sure they were done correctly. i agree that management should be the ones doining the audits. they know what they are looking for. (i will grudgingly admit that it can be a good learning experience.....if you take the time and effort to do it well. but most don't have time to do that). a second problem is that co-workers can be very irritable when you start pointing out their defficiencies. better leave that to management.

and, one chart audit per day is way too much.

[Retired R.N.]

We had this very problem where i work. They were requiring 3 chart audits per month for each of us. I am sorry, but it takes all my time to take care of the patients and to Document all the increasing crap they want us to document, that i rarely have time for lunch or even bathroom breaks. ...

dorimar:

It does NOT improve your efficiency to skip meals or bathroom breaks. The only time you should ever consider postponing meeting your own bodily needs is a time when you are having a life-or-death emergency with a patient in the middle of a code.

[jetscreamer101]

I think chart audits ought to be done by management. I personally do a small chart review on charts of residents whose Dr. is coming to do rounds. I review charting, meds, VS, weight changes, make sure labs results that they have ordered are there. The only reason I started these reviews are so I'll have an idea about whats been going on with each res so (hopefully) I won't look like an idiot when they ask me a question about them. I also do a diabetic review for each diabetic (HgbA1C, FBS, hypoglycemic medications, and results of Accuchecks, etc.) Overall it has improved the majority of res. HgbA1C's. Thats about all I have time to review and I'm into OT most every day as it is.

[zacarias, ASN, RN]

My hospital is doing the same thing!!! I always make it a point to update the Kardex (even if I think they aren't that useful) and make sure all the things that are supposed to be filled in (according to JCAHO) are filled in. I do this for all my admits and also try to do it on all patients I get that other nurses haven't done.

Doing the audits makes sense I guess except I feel that management doesn't acknowledge how some of us REALLY try hard to have the documention up to par.