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Auditing nursing documentation

I hope I'm not double posting here... I saw a couple pay check threads, but more for visiting nurses than office staff.

My HHA hires new grads (including me 3 years ago)

Our field staff document really badly. most are 2 year RNs or LVNs and don't know how to document. I once asked in a meeting of ~25 nurses "What does ADPIE mean?" and NO ONE KNEW!!! at my school, every lecture ended with "and then you apply the nursing process and what should you do class?"

I clean everything up, spell out the nursing process, dot the t's, cross the i's (If you catch the typo, maybe you can be a documentation auditor too!), make sure that problems have interventions; I'm amazed how many nurses notes look like a rubber-necker describing a car accident rather than a HCP identifying and solving problems, interventions have orders, goals are being met with reasonable efficiency and send it back to nurse for confirmation. (and did you hand write an incident report for that fall?)

Because we are a growing HHA, I focus on teaching the nurses, because In two months there will be a new batch of new hires and I can't be fixing everything for everyone forever.

It's not just paperwork - unfortunately I'm usually looking at notes that are 3 weeks old, but I see lots of pt care issues and make sure that they get fixed. better late then never, right? TEACHING is always my focus, both for patients and nurses.

I think I was worth $30/hr 18 months ago, and I told them. I just got that "raise" last week. Especialy in the past couple months I feel like the value of my 4-year degree has really started kicking in and I am as much a nurse educator as an auditor.

If you do this kind of work:

1. where are you? (I'm in northern california)

2. what are your responsibilities? what else to you do?

3. the important one: $?

You are discouraged because people aren't familiar with the acronym? Are you implying that new BSN nurses might be better at home health documentation than ADN grads?

Hey, my daughter attended LVN school and encountered ADPIE there. It is not confined to BSN programs it seems!


Has 43 years experience. Specializes in Vents, Telemetry, Home Care, Home infusion.

Hi...sure sounds like you are functioning in a Performance Improvement position, reviewing documentation to ensure meets Medicare and insurance guidelines to avoid payment denials AND more importantly, accurately document care provided is meeting QUALITY standards.

Our agency initial orientation is 30 days with mix classroom and field visits. New staff are buddied with an established RN throughout first 6 months with final review at 6 months. Our educators go out with new staff for first revisits then OASIS admit + review ALL visit notes/med list/OASIS/discharge summary to ensure accurate documentation until they feel newbie performing well. They get one-on-one peer counseling along with educators.

Our turnover rate is less than 10%, daily census now 3,000 patients + high quality scores = to or above state/national norms and beating competitors in our market. Key is Education and PI department working together to get new staff up to standards ASAP and provide ongoing support.

When interacting with staff possitive interaction "your doing good but tweeking notes will make your care shine" rather than negative approach "what were you thinking with this note, don't you know how to do OASIS yet" will yield best results.

Our new grads start at $30.00/hr with full benefits so your salary lower for higher level of responsibility. Do you report to a Quality Improvement Manager ? What are their expectations of your position. Track your Medicare HH compare scores to show how quality improves or declines due to your efforts.

we are a very small company. family business.

We don't really have a Quality Improvement Manager. Our quality control involves (quartly?) check lists that are rushed through in a time-crunch panic. My "reporting" is pretty much confined to if they remember to ask me if I have any problems when they're thinking about the topic.

My only official responsibility is to make sure our paperwork doesn't get us in trouble, and change document status from "sent to office" to "completed". everything else I do is pretty much just stuff I think may help with that goal. My boss is OK with me changing paperwork however I want. I am NOT comfortable with that. I change typos, pedantic details, and stuff that i check with the nurse in question.

If your new grad get $30/hr, then what does the educator make? I would love to go on visits with new hires, but can't imagine having the time for that. They tell me they've been looking for someone else to work with me (for a long time now) I bet we could find that person if we describe the job like you did.

Re: caliotter3

I apologise if I seemed insulting. I would expect all nurses - LVN too. to know ADPIE. especially now that I have Googled "acronymns for nursing process" and only found ADPIE in the top ten results.

Because my post is about $, it seemed important to point out I was a BSN, and how i feel i contrasted with my LVN/ADN peers. admittedly, this is my first job, so my sample size is small.

some of my most competent coworkers are LVNs - and not just the RN immigrants - other than my boss, my peer that I respect most is a nerdy LVN who should have been a doctor except for unfortunate life circumstances.

(I just had a post blocked for an old-timey swear word. Please understand, for my generation, for my geographic location, for my culture, nerd is a compliment of the highest order)

Edited by GapRN

MunoRN, RN

Has 10 years experience. Specializes in Critical Care.

Sadly I've heard a number of new grads recently tell me that the nursing process is Situation, Background, Assessment, and Recommendation. SBAR has it's place as a format for communicating a single dimensional change in condition, but for some reason it's gotten out of control and has replaced much of what we used to use the nursing process for; charting, care planning, and report.

I did not find your remark about ADPIE to be insulting, I was only pointing out that your use of that example may have been somewhat limiting as an example. I was surprised to find out from my daughter how much of what was covered in my BSN program was addressed in her LVN program. I also had an eye opener at a psych tech program. The RN instructor started out by putting any misplaced ideas out of our heads by telling us that the entire med-surg nursing (LVN level) was going to be covered in only one psych tech semester. She basically said that psych techs had to be well versed in the LVN level of nursing in addition to their psych tech education. She was trying to discount the notion that licensed psych techs are less than LVNs.

I agree with you concerning how poorly some nurses document. I have seen it at work. I am also certain that every so often my own documentation could be better.


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