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

  1. 0
    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?
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  3. 50 Comments so far...

  4. 11
    What if you didn't actually notify the family about the restraints, does she still expect the box to be checked? Unless family just happens to be sitting there in the room while I'm applying the restraints, I don't notify them in the case of an intubated patient.

    Unfortunately our ability to properly prioritize is being taken over by mandates such as these. The ridiculously lengthy q 2hr charting I'm doing on patients that are restrained, and who will remain restrained so long as they are intubated, takes valuable time away from much more important Nursing work, and I'm a little disappointed that we've so easily given away the right to decide what a patient does and doesn't need, which is really the main benefit we bring to patients.
    jadelpn, klone, VivaLasViejas, and 8 others like this.
  5. 4
    Put in a missed punch time sheet every time you get a call about work while your off work. After they have to pay you for this a few times, which they are legally required to, it will more then likely stop. Keep her on the phone for as long as you can. I mean, cant she leave you a note in your cubby?
    jadelpn, wooh, GrnTea, and 1 other like this.
  6. 3
    Remember if you didnt document you didnt do it!

    You should be happy somebody is auditing the charts and calling you to remind you to do it!
    You will feel a lot worse if in a few years time you get called to a court room because the patient or family decided to sue because you didnt inform them about the restraints.
    tokmom, Anonymous865, and GrnTea like this.
  7. 12
    It is legal, especially if they've written it as policy. Our restraint charting is audited as well. We get an email the next day if we didn't do what policy states (Q2h charting on all restrained patients and notification of family). If we are not scheduled the next day, we get a phone call. We have 7 days to fix it, 24 hours on the computer or beyond that as late documentation on paper.

    The hospital isn't looking at your charting for your protection, it's looking at it for theirs. Never misinterpret their interest as being focused on you. It's not.
    jadelpn, tokmom, klone, and 9 others like this.
  8. 9
    Quote from mcleanl
    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?
    Nope, your documentation also reflects on the facility. When the state or CMS or JCAHO surveys and reviews records, including restraint charts (which they always pull and review), and documentation is deficient, it's the facility/organization that gets cited, not any individual nurse. Trust me, if it's more than an occasional, individual, event, it will show up on your evaluation, but your superiors won't wait until then to make you aware and get the documentation fixed.

    I've worked as the night nurse doing the chart audits, and I've worked as a hospital surveyor for my state and CMS. Restraint documentation is a huge deal.
    tokmom, MassED, SuesquatchRN, and 6 others like this.
  9. 0
    Thanks all,

    I plan to bring all this up in the next staff meeting. If the documentation is that important......I mean to the point where if one single box is not checked, then someone should come in starting at 6pm to audit, so it can be done before I leave. It is not as though all we do all day is sit around checking boxes.

    People having to return to work after 12hours to check a box.....I think this is all overkill. I hate the idea of someone calling my house with such trivial issues....and yes......it is a trivial issue. In the whole scheme of everything that I did yesterday.......checking the family notification box is on the very bottom my list.

    The other point that I would like to make to all the auditors out there........approach is everything. If you sound like your salivating because you found someone didn't check a box or if you sound like you enjoy calling people to tell them that their box checking skills aren't up to par...........you are going to get on peoples nerves!!!!!!!!

    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....."
  10. 6
    So now you know, both from your own management and some insight from posts here in this thread, that complete restraint documentation is important and why.
    psu_213, tokmom, Mom To 4, and 3 others like this.
  11. 3
    Actually Altra ..............what I am understanding is that we aren't documenting for better patient care but to satisfy TJC. As a nurse......I find that very satisfying (yes, I am being sarcastic). There are two camps of people........one camp that can admit how ridiculous this all is and the other that seems to believe that has some sort of deep level of importance.
    I promise you, my patient outcome will not change based on this one box. If reimbursement is the issue.....and I sense that it might be........someone should be auditing me before I leave........so I can leave and rest my weary bones at the end of my 12 and a half hour shift.
    Sure, If box checking is where it is at and what it is all about........no problem. I could actually reduce the amount of energy I spend on patient care and really focus my time on the box checking.
    brandy1017, canoehead, and wooh like this.
  12. 7
    Quote from mcleanl
    I promise you, my patient outcome will not change based on this one box. If reimbursement is the issue.....and I sense that it might be........someone should be auditing me before I leave........so I can leave and rest my weary bones at the end of my 12 and a half hour shift.
    Is there something stopping you from "auditing" yourself after a restraint episode? That's what I have always done -- sat down once things were quiet again, or, at least, before I left at the end of the shift, and reviewed all the paperwork myself to be sure I had completed everything appropriately. It is easy to overlook paperwork things in the heat of the moment and being focused on providing the actual care to the individual, but, as you have noted, we are professionals and responsible for our own professional practice.

    And it's not about reimbursement, it is about documenting that you did provide the quality of care that you say you are providing and that the state and federal rules/regs require. As much as it bugs all of us, we all know that "if it's not documented, it wasn't done." And, yes, I realize that, on the other hand, a checkmark in a box is no definitive proof that something was done, but, short of having somebody follow every nurse and physician around, every shift, every day, it's the best system we've got.
    tokmom, VickyRN, Mom To 4, and 4 others like this.


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