who has authority to review a chart??

toomuchbaloney · Apr 27, 2015

Personally, I don't care who audits charts or what their credentials are.

If someone reviews my chart and thinks that I should chart something different than I have I will consider their opinion. If I agree then I will make an addendum to my notes. If I don't agree I tell them that I do not agree, why, and I do not amend my notes.

If the person wants something additional in the patient medical record that I am not professionally comfortable providing they will have to find someone else to write that specific documentation.

If the management of the agency feels differently about this then I would likely be looking for another job (again) as I refuse to put my good professional standing in jeopardy simply because someone in the office wants to dictate documentation language. My experience is that employers will not likely try to bully me into writing the documentation that they want rather than what was observed/done, but they will try to bully a woman.

tyvin, BSN, RN · Apr 28, 2015

In my state only an RN can do chart review. RNs must also initial after reviewing LPN charting since LPNs cannot do assessments in my state. So, to make it safe we just initial after all charting. One of the jobs of the Charge RN is to review all the charting at the end of the day to initial and make sure the LPNs & the RNs have charted right. There is so much to know on how to actually chart to get paid correctly. The biggest downfall for facilities is that the nurses don't chart correctly and they lose money. I don't know what state you're in, but that type of thing wouldn't fly over here.

jadelpn, LPN, EMT-B · Apr 28, 2015

The person you are referencing, OP, could be a medical coder. In acute care, the medical records/coding department is usually not comprised of nurses.

There are nurses who do chart checks, to be sure that everything that was supposed to be done, was. There are also internal audits of charts from nurse to nurse to be sure that charts are completed, before they go on to be coded and billed.

Once they are in the hands of the coder, they can send the chart back and ask that the RN expand on what was done, but not charted, if what was not charted is a billable item. Something I can think of off the top of my head is nebulizer treatments/peak flows. If a peak flow is not charted before and after, the entire treatment is not paid (and I have not a clue if this is everywhere, or what, but just an example). In home health, it could be wound documentation--that type of thing.

Coders are just attempting to get max reimbursement. They are not telling you what to chart, just that you are charting everything that you do. And if you are not doing it, you may find that administration may be wanting you to start.

Home Health Columnist / Guide · Apr 30, 2015

There are no Medicare /state regulations regarding who can view a chart and code it. Under HIPAA, facility needs to designate those with full access vs limited access based on job description. Coding used to be a train on the job position for those who had a interest in repetitive work, computer savy, understood home care regulations and could perform work quickly. Coder position often offered to lay person in business office staff who had experience billing.

Today, Medicare certified agencies are under the gun to maximize reimbursement since paid for 60 day episode of care if more than 5 visits made: identifying correct primary homecare diagnosis based on OASIS assessment, ensuring OASIS answered correctly based on Medicare guidelines; assigning ICD9/10 code based on PRIMARY discipline seeing patient, intensity of services provided and medical diagnosis; ensuring that admit visit paperwork completed in order to bill for RAP (request for anticipated payment). Employers hire staff who have experience in health care field, graduates of medical coding programs based in community colleges/trade schools or educated through courses offered by professional organizations: AAPC/AHMIA/BMSC = HCS-D home care credential.

Coders usually have full access to clinical note section of chart. With 3,200+ admissions/recerts a month, my employer is large agency has 10 RN Utilization Review coders and 1 clerk with AS in allied health/medical billing and coding -all certified with HCS-D credential.

They review entire OASIS admission assessment and 485 plan of treatment to ensure meets agency, insurance and coding guidelines comparing referral information to data entered by staff. When they find discrepancies, they send case communication note/email to staff who completed documentation. All plans of treatment are signed off by the UR RN coders and sent for physician signatures.

Smaller agencies in my area have clerical coders review referral + OASIS, a then assign codes with Clinical Managers responsible for reviewing plan of treatment and contacting staff for corrections. It is perfectly acceptable for your agency to have an unlicensed staff doing coding review and contacting staff for corrections.

caliotter3 · Apr 30, 2015

Personally, I don't care who audits charts or what their credentials are.
If someone reviews my chart and thinks that I should chart something different than I have I will consider their opinion. If I agree then I will make an addendum to my notes. If I don't agree I tell them that I do not agree, why, and I do not amend my notes.
If the person wants something additional in the patient medical record that I am not professionally comfortable providing they will have to find someone else to write that specific documentation.
If the management of the agency feels differently about this then I would likely be looking for another job (again) as I refuse to put my good professional standing in jeopardy simply because someone in the office wants to dictate documentation language. My experience is that employers will not likely try to bully me into writing the documentation that they want rather than what was observed/done, but they will try to bully a woman.

Amen.