Charting Critique?

[LTV950rn]

Alright, first time starting a thread.

Here's the deal. Without giving too many details, I do extended care nursing and do a good deal of training new nurses. Myself and a few other nurses do the majority of all training for nurses in different homes. We are NOT supervisors by any means.

While working my overnight shift tonight, I received an email from one of these aforementioned trainers titled "[patient name]." So I'm thinking, ok, this is information about this particular patient I need to know? Nope, it was an email addressed to myself and two other nurses (not trainers) who work with the patient, informing us that a tiny bit of the charting was not right and if we did x, y, and z, it would then be correct. He then signs the email with a thanks and his name!

Am I wrong to have been rubbed the wrong way by this? This person is not my supervisor (and in fact is my equal) and took the time to look up charting from each day I was working there. I also do not think it was appropriate he was checking up on the other nurses either. Not to mention, the "incorrect" item, without getting too detailed, does not compromise the integrity of mine or anyone else's charting by any means. (liken it to maybe a misspelled word) In my sleep deprived stupor, I almost shot off an email to my real supervisor, but decided to take the high road and refrained.

I think I just needed to vent! Any thoughts? I normally am pretty mild mannered, but this really bothered me!

[netglow, ASN, RN]

This person probably was given the task to "audit" charting. Your company is trying to stay out of trouble, and making sure that what all of you chart will pass whatever they fear of in the way of legalities. You say you have no supervision and most likely none of ya really do have much training from your company. This is a HUGE problem with HH and hospice. HH and hospice are BIG TIME money businesses. Many are now hiring NGs who have had no substanial training because they are cheap and disposable. However more and more you hear of HH and hospice co.s getting audited. So it's not such an easy money game for these companies now. Thus they get people to review and try to get you to change your charting. I've read here on Allnurses that some companies actually go ahead and change your charting without you being aware.

Sometimes this is internal auditing is done by someone who knows what they are doing, and sometimes not. I will tell you that IMHO the reason for this auditing can also be (especially in hospice) to assure that your charting is such that it will not jeopardize eligibility for payment to the company. If your patients are no longer in need of care, well then, your company will not get paid anymore and needs to find more patients...

If your company internal audit is done in a way that teaches you something that you were glad to learn about charting, then great, be glad for the help.

[Hospice Nurse LPN, BSN, RN]

Part of my job description is to do chart audits. It is sometimes a thankless job, because you are pointing out errors others have made. But in the long run, it's better to have someone internal catch your errors than the state. It could mean a loss of billing.

We all make errors at times. Several times I've had my notes put back in my mail box before making it into the chart.....forgot to sign something, or a missing time in or out, etc. The way I see it, the more eyes on the paper trail, the better to catch small (or large) things that could end up being lots of $

[merlee]

Completely inappropriate to use a patient name in the subject line, even if this is company network email.

But chart audits are done frequently by our peers, or at least by people who are not our supervisors.

Make the changes if you can, without rancor.

[ninjago]

We have chart audits, too. I'd do the changes needed if I were you, not only is it for the billing but just in case it goes to court at least you're covered.

[DookieMeisterRN]

When I did home care I always looked back at previous nights charting to see if anything significant happened. It sounds like it is a private home you go into? It is especially important to use sometimes the 'right' wording in your charting because insurance companies can be very difficult to get reimbursement over silly things like nursing notes. I've had other nurses give me a heads up about my charting before. I personally appreciated it because it meant I didn't have to drive all the way into the company office to make corrections.

[nkochrn, RN]

I think everywhere ya go someone has to be the perfectionist that finds all the itty bitty details that aren't right. I wouldn't get too worked up about it, I'd probably just make whatever corrections needed made. I wouldn't take it the wrong way "checking up" on your charting. I usually read back through the nurse's notes from the previous shift on all my patient's to make sure nothing was left out in report. I'm in an acute setting and have never done HH or hospice but would imagine that you don't have as much of a 'report' for these so the previous charting is probably useful to read through.

[caliotter3]

One of my employers at one point in time had a 'clinical specialist' who was an LVN. Never figured out her function (although I saw what she spent a good deal of time doing), but at least the office had her there and they were paying her. Maybe this person has been given some actual duties. I would say nothing because if you do, you can rest assured that you will be skewered. A matter of fact inquiry the next time you see the supervisor might be in order.