Quote from spectral_ev
Thank you. I think it is pretty shaky to have a nurse putting diagnoses into the record when we don't diagnose. Our office staff used to be better about getting the diagnoses and putting them into the program. Now I'm getting pressure about the coding, which is a whole area I don't know well and don't want to unless I am paid for the office time. It's hard enough to wedge in some actual nursing care on admission, when there's all this information to chase.
I heard that in France they have a card that every patient carries and practitioners can use it to access their medical records. Lost information is one costly problem in the USA.
I agree with all the above.
(Field/Road) Nurses really aren't trained in coding and it can cost the HH agency a bundle if not done correctly.. not to mention audits and being kicked into review for denial of payment. As I said, even the referrals we get from the MD offices aren't coded correctly often times. We can't use them if they are wrong, we give all our referrals to our coders to verify and correct if necessary.
That's why I would never do case mgt. Our agency doesn't use that model. We have office nurses for office stuff, and road nurses for the field.
Once the OASIS has been coded and "sent" (billing) I get them and write up the 485's (POC) for each one and then it goes into the hard chart from there.
What I love so much about where I work is that we ALL work together as a team.. both office and road nurses alike. We are truly a team, and we help each other out in all the many facets of the business.