Auditing nursing documentation

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

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.

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.