Care plans & sig changes

[OHIOGIRL08]

How long do you have to update care plans after a resident has had a sig change? I did a sig change on a resident the 1st part of Nov, well she continued to decline, so I updated the care plan for the later part of Nov, but I made a mistake and put the 25th on it, instead of the 24th, I'm human right ? Any way, this resident got a NG tube on 11/23/08 but I left the eating = ext x 1 assist, my theroy was the NG was a acute thing, not for the care plan at that time, I always thought that you have 14 days to do or update your care plans from the date of the sig change. Any one have anything they can add? I can't change the care plan because our computer system locks them out if the reisdent leaves the facility and she did, to me it's simply a data mistake, I simply need to fix it, right, or am I like not taking this seriously enough?? Help....

[CapeCodMermaid, RN]

I don't mean to be fresh but do you own a pen? You can always update a care plan...cross out the date and insert the correct one. We change our care plans...mostly the falls careplans..sometimes as often as weekly.

[OHIOGIRL08]

I Agree With You, But The Problem Is, Our Care Plans Are All On The Computer, We Do Print Them Out, I Said To Just Update It On The Paper One, Just Like We Did On The Old Ones We Did On Paer, But I Was Told No.......that Once It Was It The Computer, And The Person Was Discharged From The Facility, Which This Resident Was, That I Can Not Change The Care Plan??? I Had The Same Thinking You Did, Give Me The Pen..

[edhcinc]

Which record does your facility consider to be the LEGAL MEDICAL RECORD? The hard/paper copy or the electronic record?

If the paper copy is the legal medical record, you can make your corrections via a note on the care plan. If the electronic record is the legal record, you can enter some kind of addendum/correction (as a nursing clinical note) with an explanation.

OR--you can deal with it as part of your QI process. Most facilities review records at discharge--if a problem is found, it is noted on a log of some type, with a corrective action and method to monitor and prevent in future.

Any electronic medical record system should allow you to correct an error with a "time stamp" indicating when the correction was made.

Good luck!

[achot chavi]

are you the only nurse who updates careplans? where is your staff? anyone could and should update any sig change- we do it within 48 hours

[OHIOGIRL08]

I AM NOT SURE BUT I BELEIVE THAT THE COMPUTER IS THE HARD COPY, THE PROBLEMS IS, THIS RESIDENT WENT TO THE HOSPITAL , AND SHE WAS DISCHARGED FROM OUR FACILITY, WHICH LOCKS HER OUT OF OUR SYSTEM THERE IS NO WAY TO GO BACK INTO THE CARE PLAM, SHE'S LOCKED OUT, I CAN UPDATE THE PRINTED CARE PLAN BUT I WAS TOLD THAT DIDN'T MAKE ANY DIFFERENCE, IF THE RESIDENT WAS TO RETURN TO THE FACILITY, THEN I COULD BRING THE CARE PLANS BACK AND UPDATE, BUT IT LOOKS LIKE SHE'S GOING TO BO GOING TO HOSPICE, SO THAT MEANS THE CARE PLAN IN THE COMPUTER CAN NOT BE FIXED. BUT I DON'T SEE WHY I CAN'T USE THE PAPER ONE, IT'S THE SAME CARE PLAM, JUST PRINTED OUT, OUR COMPUTER SYSTEM IS ADL, I SHOULD HAVE UPDATED / CORRECTED THAT CARE PLAN BEFORE THEY DISCHARGED HER IN THE SYSTEM, AND YES I AM THE ONLY ONE WHO UPDATES THE CARE PLANS ON MY HALL, WE HAVE 2 MDS NUSRES AND WE SPLIT THE BUILDING, AND WE EACH HAVE A DIFFERENT CASE MANAGER.

[edhcinc]

Hi--be cautious of "I was told"...what is the written policy?

IF you use your computer program for clarity, ease, and standardization, and print documents out of this program for placement into a paper (hard-copy) medical record, your Medical Records policy MUST state what your facility considers to be the LEGAL medical record, since you are using what is called a "hybrid" system.

From what you have said, your PAPER record is the LEGAL record. If this is so, don't worry about the computerized version--your corrected paper version should indicate the accurate information.

If you were using a total electronic medical record, you would not save any printed documents. The electronic record IS the medical record--and your system would allow corrections (not lock you out) at any point.

Good luck.