Charge Charting: Correcting charts after discharge for billing

Altra, BSN, RN · Oct 4, 2014

Hypothetical situation: You run Business X selling widgets. Employee A routinely does not charge 10% of customers for their widgets. They are the same great widgets and customers are happy ... but you're not getting paid for them. How long will you retain Employee A?

Please complete your charts - the first time. If it's been pointed out to you certain items that you're repeatedly missing, like infusion stop times, make yourself a little checklist/cheatsheet to carry in your pocket for a few days to help modify your habits. You can do this.

caliotter3 · Oct 4, 2014

Hypothetical situation: You run Business X selling widgets. Employee A routinely does not charge 10% of customers for their widgets. They are the same great widgets and customers are happy ... but you're not getting paid for them. How long will you retain Employee A?
Please complete your charts - the first time. If it's been pointed out to you certain items that you're repeatedly missing, like infusion stop times, make yourself a little checklist/cheatsheet to carry in your pocket for a few days to help modify your habits. You can do this.

Yes, this. And you never know when those little piles of "fix this" sheets are going to play a big role in your performance rating.

akulahawkRN, ADN, RN, EMT-P · Oct 4, 2014

Yes, this. And you never know when those little piles of "fix this" sheets are going to play a big role in your performance rating.

Yes, especially when you've already given them a 2 week notice and arranged to stay on as a PRN... You now have a big target on you.

Kalipso · Oct 5, 2014

I understand the business side of charting and how it affects the bottom line and my job. I would like to chart completely the first time around myself....not just because of billing purposes but because it provides better care. But at this time let us not worry about my employment at this job because I don't care if I do or do not continue to have employment at the instuition.

My question is about the legal ramifications of charting things 3 or more days after a patient is discharged. I don't care how bad they need the money, if it jepordizes my nursing license then I shouldn't do it.

Futhermore, if this institution wants more complete charting they should hire more nurses. I am literally working in a situation where it comes down to either I take care of my patients or I chart. They should be one in the same Altra, but maybe you have been fortunate enough to work at a facility that has enough staff that you don't have to choose. At this facility it is common that end times and other things are missed by ALL the staff so frequently that there is a daily stack of charts with nurses names on it to go back and fix so they can bill the patient. Is this common at other facilities? It wasn't't at my last job. I was always improving at my last job when things were brought to my attention, but I was never asked to go back and chart items that I cannot possibly accurately remember for the sake of billing.

Kalipso · Oct 5, 2014

A bit more...I didn't beg to stay at this position PRN. They are woefully short staffed and jumped at my offer. I know they don't like me because they refuse to answer basic hiring questions foerother positions I have applied for. Fortunately I have worked enough other jobs that I had enough upper management from other postions to talk with potiential employers. I have another job already. I am just trying help these badtards with their short staffing for a couple of months like I promised.

Altra, BSN, RN · Oct 5, 2014

It's interesting that you view charting "for billing" as somehow secondary and not a crucial part of the job. And interesting that you don't feel that that charting certain things, like infusion stop times, reflects on your care.

Esme12, ASN, BSN, RN · Oct 5, 2014

A bit more...I didn't beg to stay at this position PRN. They are woefully short staffed and jumped at my offer. I know they don't like me because they refuse to answer basic hiring questions foerother positions I have applied for. Fortunately I have worked enough other jobs that I had enough upper management from other postions to talk with potiential employers. I have another job already. I am just trying help these badtards with their short staffing for a couple of months like I promised.

Could there be a reason they

refuse to answer basic hiring questions for other positions I have applied for.

Maybe they sense some...animosity

help these badtards with their short staffing for a couple of months

A part of being a good nurse is fiscal responsibility. If you have worked upper management then you should hove a complete understanding on why it is necessary to get as much reimbursement as possible.

Yes...this is done at other facilities. I have always done 24 hours audits on nights and yes we leave charts for nurses to finish.

Emergency department billing is very different than on the floors. It is an acuity billing. The higher the acuity the more we charge. That is why an accurate ESI is important and many facilities have gone to a 5 tier system.That is why it is so important to charge for the supplies we use. Example a patient in urgent care/non acute side hurt their ankle...ESI 5 not much for billing....but the MD ordered a walking boot.

Those boots are expensive ($225.00) if the documentation doesn't reflect that it was given and instructions given...no reimbursement. So lets say in one month several employees didn't document properly....lets say 8 times....that is $1800.00 for one month...that is $21,000.00 a year on the ONE item!!! It is imperative that nurses understand that it is imperative that they document.

I gave documentation meetings every month all 3 shifts. I have sent the time doing chart audits myself and handing the nurses a bill for the unchargable/non reimbursed items. A light bulb went off for them...the compliance jumped to 92%.

Kalipso · Oct 6, 2014

Esme12 and Altra, I do not see charting for billing as different from just regular charting. I realize it's importance for billing AND for patient care. However, at other facilites that I have worked at we did chart audits, staff meetings, and individual meetings to improve our understanding of what we were missing, how to improve, and how it affected the hospital. I HAVE NEVER had to go back and change charting on a patient SEVERAL DAYS after they have been discharged from a facility. Mostly because I was told it was unethical. Why? Because how can I accurately document times on events of a patient I haven't seen for says? Do you not think that a lawyer could not pick a part a chart that had 2 and 3 day gaps in the time an infusion end time was charted? Most computer charting systems time stamp everything you chart.

Eame12 I appriciate your detailed answer. At least now I know there are other hospitals that complete charts long after a patient has been discharged.

To both of you, I do not disagree that accurate charting is an essential part of nursing care, but would not believe you at all if you said you have never had to chose between charting and doing something for your patient. I would have to.question when the last time it was that you were working on the unit as a staff nurse if you are trying to tell me that your employees don't often forget to chart essential/billing items. Since you both sound like managers I would gather that this issue is so seldom because you make sure your ER is frequently filled staffed. Kudos to you.

Yes, I have animosity for these employers. I told them 8 weeks in that I felt their ER was very disfunctional due mostly to a lack of leadership. At that time it had nothing to do with the charts. Mostly due to an MD playing putting a suicidal patient in a regular room instead of the safer psych room because the sitter didn' t like that the psych room or staff singing 'staying alive' during a code when the patient's family was right outside the door....I really could go on. I don't trust people here to make good decisions and so when they asked me to go back and 'fix' charting on patients that were discharged DAYS ago it seemed a little sketchy to me, mostly because no one has ever asked me to do it, for at other positions my charting errors were brought to my attention as statistics as to what I forgot to chart and I was asked to improve the percentage, NOT to go back and add the missing information.

Anna Flaxis, BSN, RN · Oct 6, 2014

My manager does chart audits and has asked coworkers to complete charting when he finds deficiencies. This doesn't seem unusual to me at all.

I was taught that it's fine to go back into a chart to document something you forgot at the time, so long as you make a note that it's a late entry. For example, I took care of a critically ill patient and was so busy providing care that the charting was abysmal. After we transferred her out, I sat down and combed through the chart and added some notes here and there as "Late entries". The previous nurse, who had already left, hadn't documented a med. I know the med was hung because I saw it infusing, so I checked the Omnicell to see what time it had been removed and by who, then just documented the med for that time by that person. I was told this was okay to do.

Now, whether I would come in on my day off to do this is another story. If it can wait until next time I come to work, that would be preferable. But if I'm about to be off work for an extended period of time, then I could understand them wanting me to come in on a day off.

tarotale · Oct 6, 2014

Hypothetical situation: You run Business X selling widgets. Employee A routinely does not charge 10% of customers for their widgets. They are the same great widgets and customers are happy ... but you're not getting paid for them. How long will you retain Employee A?
Please complete your charts - the first time. If it's been pointed out to you certain items that you're repeatedly missing, like infusion stop times, make yourself a little checklist/cheatsheet to carry in your pocket for a few days to help modify your habits. You can do this.

great example showing where the healthcare in this country has become... just that: Business/Industry. I do this for money, and I have no respect for it.

Esme12, ASN, BSN, RN · Oct 6, 2014

Esme12 and Altra, I do not see charting for billing as different from just regular charting. I realize it's importance for billing AND for patient care. However, at other facilites that I have worked at we did chart audits, staff meetings, and individual meetings to improve our understanding of what we were missing, how to improve, and how it affected the hospital. I HAVE NEVER had to go back and change charting on a patient SEVERAL DAYS after they have been discharged from a facility. Mostly because I was told it was unethical. Why? Because how can I accurately document times on events of a patient I haven't seen for says? Do you not think that a lawyer could not pick a part a chart that had 2 and 3 day gaps in the time an infusion end time was charted? Most computer charting systems time stamp everything you chart.
Eame12 I appriciate your detailed answer. At least now I know there are other hospitals that complete charts long after a patient has been discharged.
To both of you, I do not disagree that accurate charting is an essential part of nursing care, but would not believe you at all if you said you have never had to chose between charting and doing something for your patient. I would have to.question when the last time it was that you were working on the unit as a staff nurse if you are trying to tell me that your employees don't often forget to chart essential/billing items. Since you both sound like managers I would gather that this issue is so seldom because you make sure your ER is frequently filled staffed. Kudos to you.
Yes, I have animosity for these employers. I told them 8 weeks in that I felt their ER was very disfunctional due mostly to a lack of leadership. At that time it had nothing to do with the charts. Mostly due to an MD playing putting a suicidal patient in a regular room instead of the safer psych room because the sitter didn' t like that the psych room or staff singing 'staying alive' during a code when the patient's family was right outside the door....I really could go on.
I don't trust people here to make good decisions and so when they asked me to go back and 'fix' charting on patients that were discharged DAYS ago it seemed a little sketchy to me, mostly because no one has ever asked me to do it, for at other positions my charting errors were brought to my attention as statistics as to what I forgot to chart and I was asked to improve the percentage, NOT to go back and add the missing information.

I never said I was always a manager. I have been a manager but it certainly made a difference as a staff nurse to document accurately. If the entry is documented as a late entry it is perfectly legal.

This department seems to have issues and I wouldn't stay employed there...singing staying alive during a code... :facepalm: . People never cease to amaze me.

I have always written down finish times on my cheat sheets in my pocket (nothing more than the usual paper towel) so yes I keep track. Accurate charting is not only essential to patient care it is essential to keeping your behind out of court.