This is a long one, forgive me...I was recently called into my supervisor's office and was told that there had a been fall out regarding a patient I discharged sometime in December. I was told I did not perform Coumadin teaching for a patient who was new to the drug, and now the hospital will not be getting paid for the patient's stay as the chart had come under review by medicaid. Now, I know, without a doubt in my mind, I had given the patient's family (patient was basically stone deaf and only spoke a rare eastern euro dialect - I had to communicate with him by drawing pictures and use of hand gestures) teaching regarding his diagnosis, risk of bleeding, dietary restrictions and need for follow up appointments. Coumadin teaching was also documented on previous tour as given by the night shift. However, because there was no copy/proof of the teaching in the patient's chart it is going down that patient was discharged improperly. Seeing as it was too late to go back and put in a note, I had to just take it on the chin even though I truly feel I did the best I could considering the situation and the resources I had available. I work on a very busy, understaffed unit that has every kind of patient you can think of from near death to psych to walkie talkies. 2 RN's typically due 5-6 admits, 5-6 discharges, and numerous transfers daily, all without help from CNAs or even a clerk usually. It's a very difficult and dangerous place to work.
My question is, seeing that a note could make all the difference in proving if one had actually done the teaching they said they did - would it be unethical to go back and check the discharges I had done in the past couple of months to make sure everything is as it should be? Ever since the sit down, I have changed my style and I am over compensating in the amount of teaching and documentation I perform but I can't see any other way around it. As a new nurse, I'd appreciate any input, thank you.
Mar 19, '16
Why didn't you secure an interpreter and try to obtain patient education materials in their language? If the documentation is not there it did not occur. Most often patient education prints with the discharge instructions in local facilities
Mar 19, '16
I tried but the patient only spoke a dialect of Slovakian. There were no interpreters at the hospital who spoke the language, and the phone interpreter I found was unable to communicate with the patient due to the patient's hearing deficit. There are no teaching materials available in that particular language from the hospital. The teaching I provided was directed towards the patients family members when they came to pick him up and were actually the only ones who could communicate with him. Patient education was given for DVT and coumadin but unfortunately only the DVT portion was documented as given.
Mar 21, '16
I'll address your fundamental question -- no, I do not think you should enter new documentation on all the patients you've discharged in the last few months. That pattern of late documentation would appear highly questionable. If you believe you also failed to document anticoagulation education on other patients, relay this information to your manager and ask for direction.
Mar 22, '16
^^^If this is indeed what the OP is asking, to go back and retrospectively document, I think it is generally a bad idea. I don't know if your hospital uses an EHR, but many EHR systems are set to lock the encounter/chart notes after a period of time so that changes cannot be made. The chart can be unlocked for good reason, but this event would not qualify. In this case, I would not even create a contemporaneously-dated addendum saying I think I remember doing patient education on this discharge a few months back. Your facility risk manager can speak more to this.