Chart Auditing and education

Yes, LPNs! Sorry, my mind is on auto pilot right now.

What are the policies behind LPNs reviewing RNs charting and LPNs overseeing RNs education and orientation training? I can't seem to find an answer on my State Board and was curious to know about this.

Is there a specific policy at your organization? And is this a hypothetical or is it happening? There are scope of practice differences, so an LVN/LPN who was staying within his/her scope of practice could provide training or education to the extent of the scope of the practice. Going beyond the scope of practice in anything (charting, overseeing training) is not something that administration should ask of any nurse. Curious to know what others think.

I don't believe there is a written policy specifically for LPN's overseeing RN's charting, including OASIS visits which can only be completed by an RN. The LPN is reviewing all charting including RN visit notes for home health and oasis start of care and discharge visits and overseeing all training for new hires including an RN skill check list.

Putting this into perspective, another question could be asked if it is appropriate for a CNA to audit an LPN's documentation. Or a physician assistant to audit an MD's charting. I guess it depends on the type and extent of the audit.

I imagine that if the LPN was auditing the RN charts only to see if every form was filled in and signed off, then it would not be a problem. If the LPN is also auditing content of the RN narrative notes or appropriateness of the checked boxes, then that may be working outside the scope. Just my opinion. Not sure if it is right or wrong.

In regards to the chart reviews, I think it would depend on the type and extent of reviews being done. An LPN could review documentation to ensure quality elements were addressed, all the required boxes were checked, etc., but should not provide direction on the care plan itself. And I would think only an OASIS-qualified clinician should review OASIS documentation.

The education and orientation piece is more tricky- I don't feel good about that because of the differences in scope of practice. I suppose it would be okay for an LPN to sign off an RN on certain skills that both disciplines would perform, but not all aspects of the RN's orientation.

My state board's guidance was vague, so this is just my opinion.

I agree with Nurse on the Go.

Not in home health, but I ran into this at a SNF as the inservice director was an LPN. Actually she a did a great job orienting me to the policies and procedures of the facility and performed skills check-offs that were in both of our scopes of practice. She was very cognizant of the scopes of practice/ roles, but honestly most of the orientation was perfectly appropriate for her do. In some cases, it was showing me where to locate specific policies/ procedures that were only performed by RN's at that facility. An RN did any skills check-offs that were RN specific (either per policy of the company or per scope of practice).

My state's scope of practice, especially for LPNs, is rather vague in areas.

As for chart audits, there are so many "meanings" to audit. Where I work now, there is a chart audit checklist that simply looks to see if certain documents are present and signed - nothing else. Even our HHA's and volunteers can complete these audits. Clinical audits on the other hand are performed by our Quality RN and quarterly each RN is assigned a peer audit.

If you concerns, consider approaching the LPN performing your orientation in a pleasant, non-confrontational manner to seek more information or check with the RN within your chain of command (DON, Manager etc).

This is an important question and likely may not be the first time it's come up. Or if it is, maybe it's time to reevaluate the process.

Thank you all for your responses. I don't want to rock the boat and feel that if I say something, the company will take the side of the LPN as they have said that they are lucky to have an LPN that does more that she should be doing. I feel like there are some lines being crossed but the State Board does not list these in "stone". I have charting sent back to me for correction for notifying an MD of a patient's BP when it's not outside of our reporting parameters but it's not anywhere close to the patients baseline or when she believes I should of educated on something that was not the focus of my visit. It's frustrating but I don't think she should be telling me how to carry out a care plan for a patient who she has never met. I also thought that only RNs could assess unstable patients or assess patients with new signs and symptoms?

Putting this into perspective, another question could be asked if it is appropriate for a CNA to audit an LPN's documentation. Or a physician assistant to audit an MD's charting. I guess it depends on the type and extent of the audit.

I imagine that if the LPN was auditing the RN charts only to see if every form was filled in and signed off, then it would not be a problem. If the LPN is also auditing content of the RN narrative notes or appropriateness of the checked boxes, then that may be working outside the scope. Just my opinion. Not sure if it is right or wrong.

That's personally my opinion too. The LPN is not only making sure everything is filled out but commenting on my plan of care and my focus for the visit and my descriptions of patients symptoms. I don't feel that it's in her scope to assess my assessment and comment on what the appropriate interventions are for my assessment.

That's personally my opinion too. The LPN is not only making sure everything is filled out but commenting on my plan of care and my focus for the visit and my descriptions of patients symptoms. I don't feel that it's in her scope to assess my assessment and comment on what the appropriate interventions are for my assessment.

Is she "commenting" on your wording for billing or compliance issues? Or is she criticizing your assessment, making comments that could, for example, come up on your yearly review? The former I would think is ok; the latter, wrong for various reasons.

I think if you look at the definition of scope of practice between a RN and LPN and for that matter unlicensed assistive staff. Some of the fundamental differences when it comes to all work other than Human resource/administrative tasks i.e. I need help with my FMLA, I am a RN and the person tasked to assist me is a LPN or a unlicensed staff member. A RN may practice under their own license. A LPN shall work under the supervision of a licensed registered nurse, physician or dentist (this is common in some states). A RN may perform a comprehensive assessment. A LPN may perform a focused assessment, care plans the RN develops and implements the care plan, the LPN may contribute to the care plan and or development but cannot develop/evaluate the care plan. Some states do not allow LPN's to provide health education/counseling but this is within the RN scope of practice. Medication management is within the scope and practice of the RN but the LPN may administer medication but there are some medication that only a RN or above can administer (usually requiring ongoing assessments)

I would not have heartburn with a LPN overseeing my administrative needs/issues, if the LPN was ensuring all audits have been completed and if I have not completed my audits and the LPN says hey I need those audits completed so I can turn them in...the only oversight I see is to get the audits done I am OK with this, if the LPN is reviewing audit content that includes any of my nursing judgment then it should come from a RN, not the LPN, for how can I take instruction from someone who I am suppose to supervise for direct nursing cares, when my scope of practice exceeds the LPN scope of practice. What if I thought an assessment or audit direct nursing task result should be the way I wanted it and not the LPN who I am speaking to, would I listen to the LPN, well yes, but I still would not change my assessment. In the end I would ultimately be the one responsible in a court of law and I most certainly would not stand there and say but the LPN told me to complete this task this way...the court would not care I would be judged by my license and scope of practice.

Sorry for the delayed follow up. I was out of the country and did not have access to internet.

The CNA has been promoted to head of the Education department and is now providing education and feedback on things such as my assessments, what I should be educating patients on (patients she's never met), and how I should be documenting exactly what I have been doing. I by no means lack assessment skills, my assessments are thorough, my follow through with patients and relationship with patients is very good, and my documentation is detailed without going overboard. The entire situation makes me very uncomfortable at this point. Soon she states she will be educating me and providing feedback to me on case managing... which she legally can not do. This is just all crossing the line in my professional opinion.