Documetation Beef!

[Nurse424]

Ok! So, I have been in health care over 20 years now working in Major Hospitals as Nursing Assistant and now for 5 years have been working as an LPN. I currently work in a LTC facility with Rehab and just left a facility that was completely Rehab but downsized and went to all RN's.

The issue, I have been an old school documentation kind of person well this facility I worked for all Rehab constantly was teaching us how to document for today's Nursing and for Rehab purposes for payment reimbursement for Insurance. Well seemingly what I learned there for documentation the floor Nurses I work with now are familiar with the same kind of documenting. I learned that documenting

John Doe is A&O X3 speech clear, able to make needs known, lungs clear, abdomen soft and supple with no guarding present. skin warm and dry, etc etc. But, with it being Rehab...we were always taught at the major rehab facility to chart the patient for example, John Doe ambulates independently with w/w and gait steady. Mr Doe requires assist with ADL's and minimal transfer of gait from sitting to standing.

OK!! The issue now at the new facility, even though several other nurses chart the same thing because they were taught the same......we are told the patient does NOT have a steady gait because they are here for rehab and that they cant have a steady gait because then insurance looks at that and states "why is that person here if they have a steady gait." Well, for arguements sake, all the nurses have been arguing this fact because for one, the persons admitting diagnosis is not for "unsteady gait" they are admitted for PN, COPD, Hip Replacement, MRSA, etc...AND if we chart that they have an "unsteady gait and that they are ambulating with w/w independently then they loose balance and fall, why were we letting them ambulate independently with a w/w if they already had an unsteady gait. They are not here for gait, they are here to recover from PN and are weak not here for gait purposes. SO, our thing is if we chart that they have an unsteady gait and are independently ambulating and fall, why did we let them ambulate ind. in the first

Well, now our MDS Nurse has taken it upon herself to "Fix" the charting of other Nurses...................UH!!!!!!!

Please...........some help and knowledge from some others of you out there in this crazy health care world

Now that we are all having a fit about this whole steady unsteady thing.....another Nurse is "fixing" other Nurses charting!!!!! Grrrrrrr

[Esme12, ASN, BSN, RN]

I was waiting for this to start.......which is going to open a whole other bag of worms about changing someone elses documentation.....what's legal and what's not......I knew the day would come when we would be told what to document just so the facility gets pain.....that day has come....

[classicdame, MSN, EdD]

well if the facility does not get paid then they cannot pay you.

I find when I audit charts that many nurses document incorrectly (or not legibly!). There are standards and your BON may have rules as well. I doubt if it is ok for someone to alter another nurse's notes.

[Nurse424]

I was waiting for this to start.......which is going to open a whole other bag of worms about changing someone elses documentation.....what's legal and what's not......I knew the day would come when we would be told what to document just so the facility gets pain.....that day has come....

Tell me about it!! And it's sad and VERY disheartening to those of us who are in this dog eat dog career for the RIGHT reason....PATIENT CARE!!!!!! I got into Nursing because I loved the care of caring and giving to those less fortunate the help they need to become independent again or to live out the end of there lives peacefully and happy. I am in Nursing for the care of patients that I enjoy doing!! I have a big heart and care deeply about everything in my job, my biggest care is my patients, and this highly upsets me...and the fact that we have two Nurses on NS for 98 patients and DS gets 5 then we get told that we are considered STNA's as floor nurses.......SO, on NS all we get is 4 STNA's BUT DS gets 12!!!! Where is THAT legal....MAN I dont wanna get old......I'm scared

[Isabelle49]

A nurses notes may only be altered by the nurse who originally wrote the note! I know this is THE rule for RN's, but I don't know what it is for LPN's. I would think it is the same, as the notes are documentation of patient care/assessment and if another person alters the document it would be considered fraud, since that individual had nothing to do with the care/assessment. If my documentation were changed by anyone, you can bet I would be on the phone to my BON in a heartbeat!

[Isabelle49]

Ok! So, I have been in health care over 20 years now working in Major Hospitals as Nursing Assistant and now for 5 years have been working as an LPN. I currently work in a LTC facility with Rehab and just left a facility that was completely Rehab but downsized and went to all RN's.

The issue, I have been an old school documentation kind of person well this facility I worked for all Rehab constantly was teaching us how to document for today's Nursing and for Rehab purposes for payment reimbursement for Insurance. Well seemingly what I learned there for documentation the floor Nurses I work with now are familiar with the same kind of documenting. I learned that documenting

John Doe is A&O X3 speech clear, able to make needs known, lungs clear, abdomen soft and supple with no guarding present. skin warm and dry, etc etc. But, with it being Rehab...we were always taught at the major rehab facility to chart the patient for example, John Doe ambulates independently with w/w and gait steady. Mr Doe requires assist with ADL's and minimal transfer of gait from sitting to standing.

OK!! The issue now at the new facility, even though several other nurses chart the same thing because they were taught the same......we are told the patient does NOT have a steady gait because they are here for rehab and that they cant have a steady gait because then insurance looks at that and states "why is that person here if they have a steady gait." Well, for arguements sake, all the nurses have been arguing this fact because for one, the persons admitting diagnosis is not for "unsteady gait" they are admitted for PN, COPD, Hip Replacement, MRSA, etc...AND if we chart that they have an "unsteady gait and that they are ambulating with w/w independently then they loose balance and fall, why were we letting them ambulate independently with a w/w if they already had an unsteady gait. They are not here for gait, they are here to recover from PN and are weak not here for gait purposes. SO, our thing is if we chart that they have an unsteady gait and are independently ambulating and fall, why did we let them ambulate ind. in the first

Well, now our MDS Nurse has taken it upon herself to "Fix" the charting of other Nurses...................UH!!!!!!!

Please...........some help and knowledge from some others of you out there in this crazy health care world

Now that we are all having a fit about this whole steady unsteady thing.....another Nurse is "fixing" other Nurses charting!!!!! Grrrrrrr

Your MDS nurse is committing a crime, it's called FRAUD, and when it involves Medicare payments, it is BIG FRAUD!

[CoffeeRTC, BSN, RN]

Yikes....what does therapy say? They will also be documenting on the gait etc and the progress they are making.

This is totally wrong...don't even get me started on the note fixing.

[MrChicagoRN, RN]

It is a legitimate concern that the charting accurately reflects the patient and their plan of care. While a pt may be have an admitting dx of COPD or s/p hip replacement, they are there for rehab, not for treatment of those conditions.

Are there some negatives you can chart? Ambulates for X feet before tiring, requires assist to get OOB or rise from chair, X person active/passive assist required.

As classicdame wrote, the house need to be reimbursed for care so you can then be paid for your services. It is illegal to alter someone elses notes, but if there is a need for the patient to be there, the notes must accurately reflect this.

How about requesting an guidelines inservice describing appropriate and accurate charting for this population?

[Nascar nurse, ASN, RN]

Just playing devils advocate here..don't get to quick with the flaming..

Your car breaks down..you take it to the shop...they give you a big ole bill for a couple thousand dollars for repairs. Do you just pay it and drive off. Probably not. You want an explanation of what the problem was, what they did to fix it and why the heck did it cost so much to fix it. Like it or not, medicare and insurance companies expect the same.

COPD and PN (pneumonia?) follow up does not require the 24 hour services of a SKILLED PROFESSIONAL nurse to manage - this can be done at home. It is the weakness that followed the illness (along with that recent hip replacment) that makes the resident require the SKILLED professional services of the therapy department. Hey, I didn't make these rules but they are rules that we all have to live with. Generally if they are there for medicare or insurance, they are only there until therapy is done (not til nursing is done).

Why bother saying if their gait is steady/unsteady. Why not "Able to walk 50 feet with w/w and one rest stop independently". Or, sometimes I just use the resident quotes "I'm doing so much better this week. I can get all the way to the dining room without getting short of breath".

[HouTx, BSN, MSN, EdD]

omg! the op's facility is just one qui tam lawsuit ([color=#0e774a]www.fas.org/sgp/crs/misc/r40785.pdf ) away from making the headlines for fraud. when this happens, everyone with any knowledge will go down. in this type of reporting, the original person who files the qui tam can end up with a very nice cash reward, so it's bound to happen.

any licensed healthcare professional who knows about this type of circumstance and does not take appropriate action is essentially in collusion with the fraud. punishment will most likely include actions by the state licensing board as well as placement on the federal "no hire" list; depending on the level of involvement, hefty fines and jail time could result.

it's not like this is a 'gray area'... every nurse knows that it is illegal and unprofessional/unethical to chart false information....... sheesh. there's no excuse. everyone is accountable for his/her own practice and actions. my advice, get another job & file a qui tam against this employer.

[caliotter3]

well if the facility does not get paid then they cannot pay you.

I find when I audit charts that many nurses document incorrectly (or not legibly!). There are standards and your BON may have rules as well. I doubt if it is ok for someone to alter another nurse's notes.

It does not take much effort to figure out that altering another nurses' notes is unacceptable, but I saw it done many years ago. The person altering the notes was the DON. She rewrote a note and wrote "rewritten", but removed the original nurse's note that she rewrote, instead of lining through it, and leaving it. When you see the DON do something like this, what are you, the lowly staff nurse supposed to think?

[o0nurse0o]

This is what irritates me! They are so busy worried about our documentations and not focused on our patient care! I know I went to nursing school to NURSE my patients! Nowadays it seems I get to do everything but! Jane is worried about getting her bed filled for money! Sue is worried about the charting so we get payment!

Well friends, what about Lady Jo who can't afford to have a 3000/day healthcare bill but your making me stock shelves, answer phones, file, watch tele monitors, chart PERFECTLY, go without my lunchbreak, rather than having enough time to tend to her trach, make sure I have clear thinking before I dose her with this med! I'm a nurse for the patient!!!!!!