Who's charting is it anyway?

  1. this is me hiding from my boss. she is always trying to make me rewrite what i have charted. let me state that i am not a new nurse and i have been in homecare for almost 4 yrs. she is very type a and gets on everyone's case, not just mine but this is really bugging me. she gets upset when i tell her that it's my name going on the document, not hers but i don't know what else to tell her. when she is trying to convince me to write it "her" way she says "it doesn't matter, it just sounds better". but then why does it have to be the way she wants it? she is so fearful of litigation for some reason (no we have never been sued) that it is really quite overwhelming. on one hand, i appreciate her expertise, on the other, i feel respobsible for what is charted and i don't always agree with her. any advice? thanks.

    beez
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  2. 18 Comments

  3. by   nurseangel47
    Sounds JUST like a clinical supervisor we obtained for a "cleaning of house" at a hospice a few years back! Honestly, that lady would've created a new legion of DRGs for the PPOs, PPAs, HMOs, and other managed care companies if only given a chance! LOL...I ended up leaving the hospice since she wasn't going anywhere anytime soon....she did get the ol' heaveho, eventually, I heard thru the grapevine...but she's still in home health care...I had an interview scheduled for a home health care agency and when I realized it was her again!never mind!I just never showed up for that interview! I could NOT believe my misfortune in stumbling over her lousy a** again! No way, no how would I ever work with/for her ever in THIS lifetime! So...that isn't advice. Just my view on micromanagers like it sounds like you have. I did NOT have a choice or an alternative answer for myself in the situation you've got, so I chose to take the high road!
  4. by   powernurse
    what has been bothering me is that where i work we are on laptops and if you do an admission you are not allowed to lock your oasis.... this is so the OMs can go into the note and "fix" it if necessary....scares me to death.... also i am getting calls all the time from the office that i need to go back into an oasis and "change" my answers to a MO questions especially when it comes to COPDers that become SOB with minimal exertion but refuse HHA services b/c they are still performing their own adls and want to remain independent with it..... they tell me that i cannot have it both ways....fact of the matter is that some COPDers DO ALL THEIR OWN ADLs..... AND smoke.... and are not homebound AND are very SOB with very minimal exertion....may not be the answer they want to hear....but it is the fact...and i will refuse to change my documentation based on their concerns which i believe are more focused on "did we score enough points for a big payment?"

    it is a constant battle :smiley_ab
  5. by   DutchgirlRN
    Quote from powernurse
    what has been bothering me is that where i work we are on laptops and if you do an admission you are not allowed to lock your oasis....
    We are allowed to lock the SOC and the oasis coordinator has to have our permission to change anything.
    also i am getting calls all the time from the office that i need to go back into an oasis and "change" my answers to a MO questions especially when it comes to COPDers that become SOB with minimal exertion yet do their own ADL's, they tell me that i cannot have it both ways....fact of the matter is that some COPDers DO ALL THEIR OWN ADLs..... AND smoke.... and are not homebound AND are very SOB with very minimal exertion....may not be the answer they want to hear....but it is the fact...and i will refuse to change my documentation based on their concerns which i believe are more focused on "did we score enough points for a big payment?"
    I wish I had but a dime for every urgent phone call I've received from the oasis coordinator! :angryfire Two problems...

    #1 PT's assesment of dyspnea and ADL's never jive with mine. During the last SOC I did, the PT happened to be there at the same time. She reported "no' dyspnea, excuse me honey...you never saw the pt ambulate! You pressed on her arms & legs several different ways and declared her dyspnea free. Puhlease. The pt has an ejection fraction of 17%, smokes 3 packs a day, ankles like an elephant. I won't change my assessment.

    #2 No I can't have it both ways. "You mean she is doing her own meds?", "She is doing all her own ADL's, cooking, doing laundry?" all this with COPD and brittle uncontrolled diabetes? Yep! Ok we'll stand by you, call the doctor and let him know we are not admitting the pt. Poof! The pt disappears from my computer! I'm fortunate to work for a company that doesn't look at the bottom line as the reason for being in business. It's just a pain to put all that time into a SOC like that.
    Last edit by DutchgirlRN on Dec 30, '06
  6. by   runrn
    Unfortunately, there are some agencies out there that are unable to make it financially without "cheating". What gets me is that they won't invest the money that it costs to properly train nurses to code correctly. Lots of dollars are thrown away because of improper coding or the sequence of the coding. It's cheap, ignorant, and illegal to try to "recoup" money in the scoring section of the oasis questions. I recommend when you fill out your oasis responses to carefully and fairly check them, giving credit where credit is due, but above all, they should be the truthfully answered according to your assessment. Check over for errors and then write the answer in bold letters smack dab in the middle of the area alloted for that question and circle it. Anytime that you must make corrections (for errors only) you should briefly explain and then write out correct number. In other words write "error made my correct response is #2" then sign your name. Don't just initial. This makes it tough as hell for anyone to game the system using your documentation (they can still change answers but it will be obvious these changes weren't initiated by you). That way if there is ever an investigation into the agency, there will be no doubt which answers were legitimately "changed" by you or not. Folks that check these things pick up rather quickly on your patterns of documentation as this is one of their many tools of fraud detection. Make it simple for them. I never thought I would see the day that nurses not only have to protect themselves with defensive charting, but really need a certified copy and a witness to that documentation. Remember, when it comes down to it, the very ones who asked you to fraudulently change your answers will throw it all back on you. Don't expect an honorable act from a dishonorable person. I think it is important to know that it is perfectly fine for office staff to question your oasis responses in cases where you indicate a HH aide 3 times a week but yet indicate the patient functions independently and safely. The first response should not be "you need to score them higher" it needs to be "please check for accuracy and congruency". It may be possible they dont need the hh aide service or not as frequently. Any time you start hearing things such as "we need 2 more points to get them to level blah blah", you are witnessing fraud within the medicare system which just so happens to be a federally funded program. Parole has been abolished in the federal prison system.
  7. by   caliotter3
    Changing of documentation should only be done if a bona fide error has occurred or if what is being suggested to you makes sense to you and you agree. Somebody telling you to change and redo your work just to justify her existence may make somebody in the office feel like they've accomplished something but all they are doing is creating dissatisfaction. Their efforts would be better spent in providing inservices to clearly explain criteria to field staff. Sometimes there are misunderstandings that can be cleared up by proper instructions. It sounds that in this situation though, someone was brought in and she is only concerned with making herself look good at the expense of others. Proper inservices, and the task of overseeing the charting of field staff would be greatly decreased. We can't have that now. This person might then need some other tasks to justify their salary.

    Unless there is something basically incorrect with your charting, if I were you, I would refuse to change it. Simple as that. If the other person wants the paperwork changed, then she should go out and make the visits that go along with the paperwork.
  8. by   DutchgirlRN
    I used to think...ok they know what they're doing, go ahead change it. The more I learned about HH I started saying "no you can't change that". I got bucked back for a while by the coder. She was driving me crazy. She evidently complained to the owner who arranged for me to have a half day session with an Oasis specialist. As it turns out (long story) the specialist told the owner I was 100% correct on the assessment and totally understood how to answer the Oasis questions and that the coder had the problem. I have heard very little from the coder since and when I do it's more like "Please" and "Thank You". I love it!!!

    Moral of the story....Stand Your Ground!
  9. by   caliotter3
    Yeah. Stand your ground. Especially when you know you're right. You're gonna end up being less popular anyway. So stand your ground. Another thought: When its lawsuit time who do you think is going to be on the witness stand talking about her/his charting? You are the one who ultimately must answer for your work. If you are really doing something wrong, then your supervisors bear the responsibility of getting you straight. At lawsuit time, they are going to be asked to answer for their responsibilities. I really don't think somebody is going to say that they kept telling everybody to change their charting and why.
  10. by   cookie102
    when i read these posts i "feel" alot of hostility....remember pt may be able to do ADL's but the key is can they do it safely,,,if things are not within their reach can they still do it safely,,,,if a pt that you feel needs HHA but refuses document in some comment section why the pt declines the aide.....i don't agree that it is someone wanting to change your documentation but make it a little more clearly understood.....try to look at it from both sides is all i am saying
  11. by   DutchgirlRN
    Quote from cookie102
    when i read these posts i "feel" alot of hostility....remember pt may be able to do ADL's but the key is can they do it safely,,,if things are not within their reach can they still do it safely,,,,if a pt that you feel needs HHA but refuses document in some comment section why the pt declines the aide.....i don't agree that it is someone wanting to change your documentation but make it a little more clearly understood.....try to look at it from both sides is all i am saying

    I answer the questions as if it were my mother, father, etc. If my Mom had surgery would I let her go up the stairs alone, would I let her bathe alone, etc...Once I have my answer I don't want it changed so that the agency can get more money from medicare. "It is what it is" and should not be changed.
  12. by   renerian
    I read all the thoughts about this post and felt a need to respond. As a person who processed a ton of OASIS and coded them as well, I found that calls often were made due to OASIS questions, conflicts in documentation, verbage or totally missed questions that as one person here posted, caused the OASIS to be unlockable. I have made many calls to nurses with this type of discussion, if a person is independent with ambulation, stairs, etc, then the admission should have been stopped if Medicare was the pay source realizing the homebound issue was not met. I have alot made calls to nurses, aides and therapists to find out more information about something that occured at the home for which alot of information is not in the note to CYA of the employee and the agency.

    On the flip side of this is I have been on the other end of that where managers asked me to change OASIS to reflect homebound status when I did not admit people if they were clearly not homebound. At times this is a non popular stance when an agency wants inflated numbers.

    renerian
  13. by   caliotter3
    [ She gets upset when I tell her that it's my name going on the document, not hers but i don't know what else to tell her. When she is trying to convince me to write it "her" way she says "it doesn't matter, it just sounds better". But then why does it have to be the way she wants it?

    "It just sounds better" is not a valid reason to change documentation. Nor is "Do it my way". As I stated previously, there should be valid reasons for changing documentation and all personnel should be inserviced on common misconceptions.
  14. by   Daytonite
    since i started studying health information management i have been learning a great deal about medical records and medicare reimbursement. your boss may just not be articulating effectively all the reasons why your charting is so important. practicing nurses are taught from school that their charting is to document what they see and do with the patient. in essence, that is what documentation should be. however, bosses are also getting pestered by the management people above them about budget and financial matters all the time. a good many home health services are paid for by third party payers (insurance companies, medicare and sometimes medicaid). what most nurses don't know is that these payers insist on documentation being present to prove that certain conditions exist and are being treated before they will hand over any money to your agency. having been a staff nurse for many years i know that most nurses don't like the sound of this, but keep in mind that we do owe our employers some loyalty and that includes doing whatever we can to help the business stay afloat. if that means documenting a little differently so that certain specific information gets into our charting so the services get paid then that's just what we have to do. the business staying open and us keeping our jobs kind of depends on this. what i have also been learning about huge entities like medicare is that they are pretty much leading all the other insurance companies around, so what they say goes. what many do not understand is that healthcare providers can get into huge heaps of trouble (going to prison kind of trouble + big fines) if services provided are falsified in documentation and are billed for. as nurses, we didn't hear about this in nursing school, but i guarantee you, it does happen. the government, in particular, wants to justify and know what every penny they are paying out is being spent for. i used to think the irs was scary, but they are nothing compared to what medicare can and will do to people who are trying to pull the wool over their eyes. on the other hand, each business wants to assure that they are going to get the maximum amount of money for the services they provide to their patients from these third party payers. consultants estimate that healthcare providers are losing millions and millions of dollars they could be legally collecting from third party payers because of failure to bill for services due to deficient charting or bad coding and billing. so, bosses want you to chart everything so a sharp biller can legitimately bill for everything they possibly can from a chart. when i worked as a coder, i was shocked at how many insurance companies and medicare just summarily declined payment of many services--period, end of story. it doesn't seem fair and has made it hard for healthcare providers to stay in business. one of the largest medical insurance providers would summarily not pay for the x-rays that were taken to confirm someone's broken bones that were subsequently treated. this kind of money adds up to millions of dollars over time. and, the healthcare providers can do nothing but refile a claim and hope it gets paid.

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