My unit management has just recently introduced pain audits that staff nurses must complete. Each nurse must complete 3 pain audits on any 3 patients in our unit each month. The patient must NOT be your own patient.
This requires nurses to open patient charts to review the patient's medication record, care plan, vital signs, pain assessments, etc. It's important to note that upon opening the patient's chart, you are greeted with a cover sheet that lists allergies, diagnoses, immunizations, and appointment history.
Now, this sounds like a clear HIPAA violation in my head, however, I believe management believes this is okay given that they are chart audits. I know I would be upset if I was hospitalized at this hospital and every nurse was opening my chart.
This looks like drug seeker/user/theft activity monitoring and more so an administer monitoring activity. You KNOW they are looking patterns. . It is their job (with out getting their hands dirty) and facility. If you find discrepancies' the administers will direct that you are accusatory and are at fault for the data . Get out of there...there is an internal problem
I had a similar thought. It is weird that staff nurses have this extra work. The staff nurse's participation in data collection sounds like a double edged sword. Will the results of your audits be compared against your own performance? Are you inadvertently building cases against coworkers? Why is the auditor not independent of the department being audited? What specifically is the goal? Improving pain outcomes or identifying medication misuse amongst staff? QI regarding patient care seems okay but becoming an unwitting investigator to quell whatever suspicions the organization has about the department is a very tricky scenario. This doesn't sound like pressure injury, CAUTI, fall type of strictly QI.
I am wondering how much more to the story there is.
mtmkjr said:
No, it's for compliance to CMS and JCAHO standards.
Questionable, especially if the auditors are not independent of the department being audited.
Questionable, especially if the auditors are not independent of the department being audited.
I know what you mean but it just isn't considered that way. Random charts are going to ultimately be audited by the outside organizations already mentioned. I'm surprised you haven't had the pleasure of encountering this activity of having staff nurses audit documentation before. The reason for reviewing them before outside agencies do is to 1) get everyone better at documenting the items that are going to be looked at (by outside reviewers)--which I have to admit, though I don't appreciate extra tasks given the state of assignments these days, the activity of auditing does tend to improve one's own charting 2) to know where we are falling short so that we can improve 3) in a different world all these efforts could actually lead to better patient care rather than just better documentation of mediocre care.
I know what you mean but it just isn't considered that way. Random charts are going to ultimately be audited by the outside organizations already mentioned. I'm surprised you haven't had the pleasure of encountering this activity of having staff nurses audit documentation before. The reason for reviewing them before outside agencies do is to 1) get everyone better at documenting the items that are going to be looked at (by outside reviewers)--which I have to admit, though I don't appreciate extra tasks given the state of assignments these days, the activity of auditing does tend to improve one's own charting 2) to know where we are falling short so that we can improve 3) in a different world all these efforts could actually lead to better patient care rather than just better documentation of mediocre care.
I agree with what you are saying to 99%. My spidey-sense is about that last 1%: is this just about patient care, or is this also about the physical handling of the meds?
Specializes in Psych, Addictions, SOL (Student of Life).
Barriss Offee said:
I agree with what you are saying to 99%. My spidey-sense is about that last 1%: is this just about patient care, or is this also about the physical handling of the meds?
Every Hospital I have ever worked with requires staff nurses (Usually Noc shift) to audit charts for the purposes of satisfying regulatory agencies and also to catch mistakes in or poor charting by staff. It is not however a witch hunt as it is usually addressed as quality improvement rather than corrective action.
Every Hospital I have ever worked with requires staff nurses (Usually Noc shift) to audit charts for the purposes of satisfying regulatory agencies and also to catch mistakes in or poor charting by staff. It is not however a witch hunt as it is usually addressed as quality improvement rather than corrective action.
Hppy
I am not disagreeing with you. I am not sure what the confusion is, if any.
Specializes in Leadership, Psych, HomeCare, Amb. Care.
londonflo said:
This looks like drug seeker/user/theft activity monitoring and more so an administer monitoring activity. You KNOW they are looking patterns. . It is their job (with out getting their hands dirty) and facility. If you find discrepancies' the administers will direct that you are accusatory and are at fault for the data . Get out of there...there is an internal problem
Nope.
Pain management is a big deal to the feds. They're looking for pain assessments, and if meds are given, is pain being reassessed after 1 hour. This was a huge thing where I last worked.
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I had a similar thought. It is weird that staff nurses have this extra work. The staff nurse's participation in data collection sounds like a double edged sword. Will the results of your audits be compared against your own performance? Are you inadvertently building cases against coworkers? Why is the auditor not independent of the department being audited? What specifically is the goal? Improving pain outcomes or identifying medication misuse amongst staff? QI regarding patient care seems okay but becoming an unwitting investigator to quell whatever suspicions the organization has about the department is a very tricky scenario. This doesn't sound like pressure injury, CAUTI, fall type of strictly QI.
I am wondering how much more to the story there is.
Questionable, especially if the auditors are not independent of the department being audited.