Chart Audits....you have to be kidding me!!!!!

[mcleanl]

Ok......I just got a call from the night charge nurse. She audits the restraint charting somewhere around 2000hrs. She called to tell me that I didn't check the box (in EPIC) that states I notified the family regarding the restraints. Every other bleepin' box was checked except that one..........she called me to tell me that I had missed that one box. FYI.....this lady was maxed on pressors, rapid Afib, intubated and lined today and started in CRRT....wasn't like I was sitting on butt all day.

She apparently will call you up to 2 times and on the 3rd time if your restraint documentation isn't perfect........you have to come back in to fix it. I work 12 and half hr shifts. Some staff members have been called as late as 2200hrs. Can this even be legal???? I feel totally harassed. I was always under the impression that my documentation was mine....done under my license. If I failed to complete everything, than it was my license at risk and that it would also show up on my evaluation.

Can management really call you for such small infractions?

[Esme12, ASN, BSN, RN]

Mu no...wooh I agree with you 100% and I am of the mindset that a check mark doesn't indicate compliance nor good/safe patient care...I think nightly auditing and having the "offender" return to work to male a check mark....but it is not illegal to make them do so. I think it's unfortunate that nurses are treated this way but I also think it is unfortunate that non compliance by the nurses requires this kind of enforcement.

[wooh, BSN, RN]

I also think it is unfortunate that non compliance by the nurses requires this kind of enforcement.

"Noncompliance." There's a move to quit calling our patients noncompliant. As usually, when they aren't "complying" it's actually a symptom of a bigger problem. I think we need to look at our colleagues the same way.

OP checked all the other boxes. While keeping an obviously very sick patient going at the same time. It obviously wasn't stubborness, or OP would have skipped charting at all. Perhaps a crappy charting system combined with a human only being capable of doing so many things in a 12 hour period? Or forget the charting system. Just simply a human only being capable of doing so many things in a 12 hour period and OP did what a nurse is supposed to do, prioritize. Illegal? No. But it's not "noncompliance" that requires this kind of enforcement. It's a healthcare system that's busy complying with regulatory idiocy resulting in noncompliance with actual patient care.

[Havin' A Party!, ASN, RN]

... If you absolutely have to call me, please say something like... "I can't believe I have to call you for this, I know you ran your butt off today BUT... this box has to be filled out..."

You're so right!

Why don't so many nurses... including sups and managers... get this???

[Esme12, ASN, BSN, RN]

I think we need to look at our colleagues the same way.

OP checked all the other boxes. While keeping an obviously very sick patient going at the same time. It obviously wasn't stubborness, or OP would have skipped charting at all. Perhaps a crappy charting system combined with a human only being capable of doing so many things in a 12 hour period? Or forget the charting system. Just simply a human only being capable of doing so many things in a 12 hour period and OP did what a nurse is supposed to do, prioritize. Illegal? No. But it's not "noncompliance" that requires this kind of enforcement. It's a healthcare system that's busy complying with regulatory idiocy resulting in noncompliance with actual patient care.

I couldn't agree more

"Noncompliance." There's a move to quit calling our patients noncompliant. As usually, when they aren't "complying" it's actually a symptom of a bigger problem.

the staff hate the ADMIN and the ADMIN thinks little of the staff....it's a big problem...no one is winning...least of all the patient.

I never said the OP was stubborn AND I stated I thought that having them return is ridiculous.

Regulatory idiocy, unfortunately was created and is there to try to make some facilities be safer.....if the general public only knew how bizarre the real world is and how stupid some educated people really are:facepalm:. A majority of facilities are perfectly fine and The JC only make recommendations....how each individual facility carries out these recommendations is totally up to the facility...however difficult and ridiculous they want to make it...now they need to make sure everyone "complies". I use the term complies as it implies some action that indicates a desire to "do as the are told"...which just is/sounds wrong.

Do we REALLY KNOW that there was one box/ Do we really KNOW that this is the OP's first and only time they have forgotten anything? NO. We assume they are telling the truth and if that is the case...this facility is way overboard and that charge nurse is on a power trip...but all in all....making someone return to work to finish paperwork, while really annoying, is not illegal.

I hear what you are saying wooh...I do....but there is so much wrong with medicine/hospitals right now and it is well on it's way to getting worse....sigh

[TiffyRN, BSN, PhD]

OP, I'm not minimizing the importance of the complete documentation others have emphasized. My suggestion to you would be to consider not picking up the phone when your facility calls (do you have caller ID like most?). I did this the other night when work called and in that case coming in to fix that situation saved me a write up that would have nullified any chance at a raise come next evaluation.

Find out the consequences of delaying your documentation on the restraint issue. If you find out it won't result in some kind of negative action, then don't sweat any more calls about it. Listen to the message, if you're inclined, call them back when convenient and fix the documentation at your convenience. If delaying the documentation will get you written up, you may be thankful for the call and opportunity to come in and fix things.

[chopwood carrywater]

I would think that it is possible in this day and age of secure high tech -relatively speaking - that a missed check box or other similar things could be resolve by having the nurse call back in on a special line that would allow the nurse to enter a PIN number and then state what they did or didn't do, and whatever other information is needed, and that then becomes part of the chart record. Possibly this could also be done on computer well.

Since there are home care organizations that use computer charting that syncs up from he field, I have to believe that it's not hat difficult to implement something similar that allows for corrections or completions from off site locations

Sent from my iPhone using allnurses.com

[elkpark]

It can wait until you're next at work. After all, the family can't get the medical record to sue you for missing that box until the patient is discharged. (And really, getting sued for failing to notify the family? REALLY? You don't have a lawsuit unless there were damages, and Billy Bob not being immediately told Mom got restraints put on is not enough damages to get a lawyer to take the case on a contingency fee.) Unless TJC has walked into the building (and I'd argue even THAT isn't enough of a reason to demand I come back to the building immediately), IT CAN WAIT.

It's not so much a matter of getting sued for something like that -- as you point out, there is no obvious injury that would provide grounds in the example given, and the likelihood of an RN getting sued for anything is v. slim. However, if the Federal or state Dept. of Health or Dept. of Mental Health rules/regs require that the family be notified, which is a common rule, it's not done, and the family complains to the state agency, the agency will investigate, and, if the facility/organization can't show evidence to the agency surveyors that the family was notified (which is the point of the check box on the restraint form), the facility (not the individual nurse) will get cited and possibly fined, depending on the state, for being out of compliance with the licensure rules/regs.

[mcleanl]

Hello All,

I have had a day to mull over everything. I still feel that it is completely ridiculous to call someone at home regarding an unchecked box. This in NO way impedes patient care.

I also stand by what I said, if 100 percent compliance is the goal then someone should be doing a chart audit before I leave.

It is interesting......the responses you get from nurses on here. Some people chose to jump on the not charted/not done band wagon, some were feeling I was lucky to have someone audit my charting to prevent a lawsuit and others jumped all over compliance. I think someone actually questioned whether or not I was telling the truth about the number of times this has occurred or if I actually left more boxes unchecked than I admitted to. Very interesting responses.

I am a Registered Nurse in the ICU for 20 years, I take care of very sick patients and I forgot to check a box.

I find it demeaning and irritating that someone would call my house to tell me that I forgot to check a box.

I find it demeaning and irritating that someone would tell me, and the staff that I work with, that management will allow us to get away with 2 offenses but on the 3rd offense we must return to the hospital to correct out mistake.

I dislike punitive management.....I find it very ineffective and offensive. We are Registered Nurses......we should be treated with respect, not like "naughty" school children. If the goal is 100% compliance, let's figure out a way to get there.

So, there were some good responses. I plan to use some of the suggestions that were mentioned here, since I will be bringing this up at the next staff meeting.

1- self auditing..... If they can run an audit.....they can teach me how to run my own audit. When time permits, I'll run my own audit.

2- Leaving emails and giving x number of days to resolve the issue.

Altra, I am not sure what to make of the quote below. Are you suggesting that I lack insight into the nature of my offense? If so.......is smacks of superiority. Just another issue some nurses have.

You know, I probably agree with you on that point.

There are nurses who have been around long enough to see the possible consequences of review of care provided to a specific patient on a specific day ... long after the actual events have transpired.

And there are those whose limited experience does not allow them to see beyond the moment.

[Altra, BSN, RN]

Like every other nurse here, I have 1000 things to do in any given shift. There is never "enough" time, so as a professional I go through the same mental process every shift that every other professional here does -- and constantly pick & choose and prioritize and re-prioritize from minute to minute. It is the nature of our work.

However, one thing does remain static. And that is the stark reality that care of a patient lives on in the form of documentation. What's more -- the chart exists as a stand-alone record of what you did for that patient, regardless of what else was happening, what time of day it was, who else was coding on the unit, etc. It is what it is.

In a 20-year career I have no doubt you have witnessed and possibly participated in some fashion in accreditation visits, state DOH licensing renewal surveys, analysis of charts when various practices/processes are examined for possible policy changes, and dust-ups when there has been a sentinel event. Reading charts after the fact is eye-opening, isn't it? Again -- it is what it is -- every single "out of compliance" (I hate that phrase, too) chart is a liability for the facility.

You've said you've gleaned some good suggestions from this thread to take back to you unit. I genuinely hope that some of those suggestions can make your unit a better place to work.

[MunoRN, RN]

It's not so much a matter of getting sued for something like that -- as you point out, there is no obvious injury that would provide grounds in the example given, and the likelihood of an RN getting sued for anything is v. slim. However, if the Federal or state Dept. of Health or Dept. of Mental Health rules/regs require that the family be notified, which is a common rule, it's not done, and the family complains to the state agency, the agency will investigate, and, if the facility/organization can't show evidence to the agency surveyors that the family was notified (which is the point of the check box on the restraint form), the facility (not the individual nurse) will get cited and possibly fined, depending on the state, for being out of compliance with the licensure rules/regs.

It's sort of a moot point, but there are no federal or state agencies that require family be notified of the use of restraints. The only "rule" that exists is that the Joint Commission, which is not a regulatory agency and cannot impose fines or regulatory citations, requires that when restraints are used for behavioral health purposes (as opposed to medical indications), family or surrogates are notified but only when the patient has already communicated they want information given. All health departments require that proper education be provided for any intervention.

[MunoRN, RN]

The main issue is that it is not the Nurse's responsibility to comply with regulations such as restraint charting. It's the Nurse's responsibility to follow their obligation to prioritize appropriately, if the facility is not supporting the ability to make it down to restraint charting on a properly prioritized worklist, then that is the facility's failure, not the Nurses.

[nurseladybug12]

During one shift that I had a pt on restraints, I was told by the CN that I had not "checked" certain boxes in Epic NV restraint flow sheet. She had made a note of it, I completed it, and I told her so. I then got called into the manager's office the next morning and asked to fix the same things, based on the note the CN had left, but she had not told the mgr that she had checked to see if it was corrected. Of course I felt annoyed, I feel annoyed anytime I am working my butt off and one of my charts is audited and I am told something miniscule is off. So I had to go back into a discharged pt's chart which was a pain in the butt to find, to see that yes I did do it as I had told 2 different people already. It is annoying to get called after the fact, they should tell you when you are at work and not be bothering you at home, because what can you do from home about it anyways? Just know that it is important, they are just doing their job, and I would say to them let's notify people of their need to correct their documentation during the shift or on their next shift and to not bother nurses at home about it.