Do people audit your nursing notes at your workplace?

  1. I was wondering..I worked at a LTC facility before..They had medical recrods people there auditing charts...I mean they will pick out anything and I would have to correct it..Now I am at home heatlh..Right now the agency supervisors and administrators are auditing charts..They are all RNs..Was wondering, they wanted my charts to be written differently and I got a warning and if I get one more warning I would have to go to an inservice in documenation..Was wondering is this like a write up? And dont every facility have these auditors trying to pick out errors?
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  2. 17 Comments

  3. by   OC_An Khe
    With the changes coming in Medicare reimbursements, we will only see an increase in chart audits, not only NN but MDs et al.
  4. by   TexasPediRN
    I have to get going to work now, but I just saw this thread and wanted to respond with one thing.

    I used to work home health, as a clinical care coordinator (I worked in the office).

    I routinely audited notes. Why? Insurance and medicaid will not pay for cases whose notes are not up to par.

    I had a case once who we had to get some of the notes re-written "pt is so sleepy" is not acceptable in a nurses note. I cant remember some of her other examples, but it was pretty bad.

    Good luck!
  5. by   caliotter3
    Our notes were audited when I worked in LTC and they are audited in home health. One of the Director of Clinical Services did the auditing herself (at least most of it) and would send out general reminders to the staff about poor documentation. People would be called into the office to rewrite their notes if necessary. I walked into the office one time and saw one of the other nurses on my case, sitting at a desk with stacks of notes on the desk, writing away, and every soul in the office didn't say a word. Nobody looked happy. I left quickly. The sad part about this is that I had given this nurse friendly hints all along about her charting. She blew me off, saying that the previous agencies had never said anything about her charting. So much for trying to save a co-worker some grief, no, rewriting.
  6. by   Fonenurse
    Note writing is an art, and if performed correctly can communicate well to your colleagues and, sadly, sometimes may be required in a court of law to keep you out of trouble! I'd try to look on an audit as a positive experience to be learned from - I spend a lot of my time auditing many things, including note keeping and it's a common problem for nurses.

    My hints and tips are:

    • Remember, if it isn't documented, it didn't happen
    • Write simply and factually
    • Learn the standard ways for documenting in your facility
    • Don't use abbreviations unless they are on an approved list for your facility
    • Read your notes, thinking all the time whether someone who comes afresh to these, without prior knowledge could understand them.
  7. by   nghtfltguy
    Quote from Fonenurse

    My hints and tips are:
    • Remember, if it isn't documented, it didn't happen
    • Write simply and factually
    • Learn the standard ways for documenting in your facility
    • Don't use abbreviations unless they are on an approved list for your facility
    • Read your notes, thinking all the time whether someone who comes afresh to these, without prior knowledge could understand them.
    omg!! EXACTLY WHAT SHE SAID!!!

  8. by   Altra
    Daily.
  9. by   Daytonite
    Don't take this as being something bad. This is the job of the medical records people. I've been studying for a degree in Health Information Management, the new official title of Medical Records. The reason they are doing this is because in order for them to legitimately bill for certain conditions and situations that are going on with patients (in order to get paid by Medicare, MediAid, or the various insurance companies) there must be documentation in the chart to back up what they are charging these third party payers for--OR--they can get into BIG, BIG trouble with the law.

    Now, I can't say why one employer gets more bent out of shape about it than another, but in LTC, the MDS report is their bread and butter and the chart must reflect the specific nursing care that the patient requires and receives or Medicare will come down hard on the facility with fines all the way to outright denying payment to the point that they can literally put a facility out of business. Then, you'd be out of a job.

    It might be a good idea to voluntarily attend a documentation inservice and take an interest in this just to be very clear on exactly what it is you need to be documenting. After all, this is your employer and you owe them that loyalty.
  10. by   FlyingScot
    100% of our charts are audited within a 24 hour period.
  11. by   Dunno?
    Quote from FlyingScot
    100% of our charts are audited within a 24 hour period.
    Did you ever have to correct yours?
  12. by   Blee O'Myacin
    Quote from Dunno?
    Did you ever have to correct yours?
    Why wouldn't you want to correct something that is unacceptable according to facility standards? A late entry is perfectly legal, and would serve your own interests should anything about that patient ever be questioned, especially if it pertains to the care that you had given.

    I think it's a good thing that charts are gone over, flagged, and entries are then clarified. We are professionals writing legal documents, it should be correct, complete and clear to anyone who reads it.

    Hope this helps.

    Blee
  13. by   Dunno?
    Quote from Blee O'Myacin
    Why wouldn't you want to correct something that is unacceptable according to facility standards? A late entry is perfectly legal, and would serve your own interests should anything about that patient ever be questioned, especially if it pertains to the care that you had given.

    I think it's a good thing that charts are gone over, flagged, and entries are then clarified. We are professionals writing legal documents, it should be correct, complete and clear to anyone who reads it.

    Hope this helps.

    Blee
    Some of the reasons why my notes are not that good is because I work at home health...There are no supervisors watching over me and I am on my own when I work..The only supervisors are the family members of the patient...What family members tell me about the care of the patient, I would have to comply...If I did not comply, it would lead to the family not wanting me there..What the home health agency wants is different in what the family wants in patient care so there was a conflict on what I wrote on my notes..

    If the home health supervisors were there with me with the family members, they would know what was happening..I am in the trenches and the supervisors are not..They are in an office building 25 miles away following rules and guidelines on what is right...They never stepped a foot in the home of my patients or met the family..
    Last edit by Dunno? on Dec 23, '07
  14. by   ASSEDO
    I read and audit nursing notes and the entire chart on a daily basis. I count all medications (other then oral) that are documented within a each 24 hour period. This is for insurance payment, to ensure that compliance with Medicare guidelines are met and verify medical necessity based on InterQual criteria. If something is not documented, hospitals lose money. Not documenting 1 IM injection, may place a patient in a lesser level of care and payment from an insurance company may not be made for that entire hospitalization or day.

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