Chart Audits....you have to be kidding me!!!!!

Nurses General Nursing

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Ok......I just got a call from the night charge nurse. She audits the restraint charting somewhere around 2000hrs. She called to tell me that I didn't check the box (in EPIC) that states I notified the family regarding the restraints. Every other bleepin' box was checked except that one..........she called me to tell me that I had missed that one box. FYI.....this lady was maxed on pressors, rapid Afib, intubated and lined today and started in CRRT....wasn't like I was sitting on butt all day.

She apparently will call you up to 2 times and on the 3rd time if your restraint documentation isn't perfect........you have to come back in to fix it. I work 12 and half hr shifts. Some staff members have been called as late as 2200hrs. Can this even be legal???? I feel totally harassed. I was always under the impression that my documentation was mine....done under my license. If I failed to complete everything, than it was my license at risk and that it would also show up on my evaluation.

Can management really call you for such small infractions?

If management called me at 2200 hours because a box needed to be checked, then guess what? I will be RIGHT there--

but if you are union, look at your contract first. Because you call me in, I clock in, and if I am there for 4 minutes or 26 minutes, you pay me a minnimum of 2 hours on call back. Thank you very much.

AND if you are unable to advise family the patient is being restrained (which must be an ICU thing--never heard of it) then what, you can't restrain the patient? Or you do, and what just "say" you informed the family? If this is policy or an order? Maybe whomever signs consents for the patient at admission is also notified that the patient can be subject to restraints for safety. Otherwise, I can't see the sense of daily phonecalls to family "we need to restrain patient xxx again" so a box can be checked. Check the box on admission with the other 999 boxes regarding family education and informing of plan of care. I am surprised you don't get more "noooo don't restrain my loved one" debates....

Yes, the late hour stinks, and it is a huge pain to haul one's butt out of the bed to go check a box, however, I will do it, but you can bet the farm I will be paid for it. And with night differential and my overtime rate too.

Muno, you might want to read your "compliance resource" a little more thororoughly (like, past the first sentence). The sentence you quote above is referring specifically (only) to JCAHO standards. The full response to the question about family notification goes on to reference NIAHO and CMS regs. The final senteence?

"And, as always, check specific state requirements."

I couldn't agree more, which is why chart what actually got done (and more importantly what didn't actually get done), as opposed to just making the charting "look good", which essentially takes away our ability to claim insufficient staffing and support. We communicate regularly with out BON compliance officer and have had them come down and meet with us and administration on numerous occasions. What "next level" beyond the BON are you referring to?

In the case of the OP, which I may have misunderstood, it didn't sound as if her/his complaints were going anywhere but to the immediate nurse manager or supervisor right now and maybe forever. It seems time to start working quickly up the chain of command, with side trips to risk management, the state dept of health, and perhaps the newspapers.

The reason she is so strict on this is because it is a Joint Commission guideline and if not followed, the hospital could be held liable. Yes, your nursing license could be effected - that is if the family takes the facility to court over the patient and restraints are brought up. I recommend making sure you click the box from now on - yes, we all forget from time to time but people who are auditing the charts are just trying to cover the facility and your license :)

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