So I think we all know about how our charting affects billing. The best example I know of this is hospitals nagging us to remember to chart the end times on IV infusions like normal saline or antibiotics. If there is no end time the insurance will not pay for the infusion and the hospital loses money. The same for like DME products such as ankle air splints or wrist braces.
My previous hospital use to audit our charts for these errors and give us a print out of what we missed. It was nice because I could tell where I needed to improve my charting. But they NEVER asked me to go back into a patient's chart and 'fix' it.
My new job audits the charts for these errors also, but instead of just pointing them out to you they require that you go back into a chart and 'complete' it. So days after discharge of a patient I'm suppose to go back into their chart and put the end time for the normal saline bolus they received, just so billing can bill the insurance. Now I can understand that money is necessary and all but I have a problem with this for a couple of reasons.
1) Any charting done days after a patient has left is not accurate. How does it look in court if they can see that I charted a note 3 days after the patient was discharged when their IV fluids were discontinued? Not to mention couldn't a lawyer tell that only all the chargeable parts of my charting were complete but that other parts were woefully neglected? How does that look?
2)I am all for complete charting. Mostly because if I have time to good complete charting that should cover both my butt and the hospital's. However, like most places I would guess, if I'm doing nursing care the correct way I usually am taking care of my patients and my charting is minimal CYA at best. I would LOVE to have the time review my charting before departing my patient's chart, but if there is only enough staff to barely care for the patients, much less take time to do clerical tasks like charting, how is it my fault that you (the hospital) is loosing money?
Yesterday I got off a 7 day stretch that I feel darn near killed me. It was no lunch, hold your pee, get out late every single day. I picked up because the department was short. Everyday management mentioned to me that I had charts that I needed to 'complete' while watching me power walk up and down the hallway. Needless to say I did not 'complete' my charts. Now I'm suppose to be off for 14 days on vacation but I get a phone call today, which so went to voicemail, telling me that I need to come in to complete my charts so that billing can be completed. I'm not going to go in. (Side note here: I've only worked at this place for 3 months, I've already turned in a two week notice but then worked it out with management to try to stay on PRN.) Anyway how ethical is it for nurses to go back and 'correct' their charting days after a patient has been discharged? What do you think? Anyone have any idea what the legal implications of this would be in court? Does anyone else do this at their hospital?
