Do people audit your nursing notes at your workplace?

[Dunno?]

I was wondering..I worked at a LTC facility before..They had medical recrods people there auditing charts...I mean they will pick out anything and I would have to correct it..Now I am at home heatlh..Right now the agency supervisors and administrators are auditing charts..They are all RNs..Was wondering, they wanted my charts to be written differently and I got a warning and if I get one more warning I would have to go to an inservice in documenation..Was wondering is this like a write up? And dont every facility have these auditors trying to pick out errors?

[ASSEDO]

I read and audit nursing notes and the entire chart on a daily basis. I count all medications (other then oral) that are documented within a each 24 hour period. This is for insurance payment, to ensure that compliance with Medicare guidelines are met and verify medical necessity based on InterQual criteria. If something is not documented, hospitals lose money. Not documenting 1 IM injection, may place a patient in a lesser level of care and payment from an insurance company may not be made for that entire hospitalization or day.

[FlyingScot, RN]

Did you ever have to correct yours?

No, we do not correct ours as that would be illegal. Instead we are given an audit report on every chart we do whether there are mistakes or not. If we have not complied with policy it is noted on the audit sheet in the area we were deficient, for instance, vital signs not recorded at the correct interval. Our system is not punitive, although I guess in extreme cases we could be called on the carpet for repeated violations. It is intended to be educational and to help us be complete. We have to sign the audit sheet to verify that we have read it and we are able to make comments if we have a reason for not following policy as sometimes happens. For the most part it just gets our attention and encourages us to be more careful in the future.

[caliotter3]

Some of the reasons why my notes are not that good is because I work at home health...There are no supervisors watching over me and I am on my own when I work..The only supervisors are the family members of the patient...What family members tell me about the care of the patient, I would have to comply...If I did not comply, it would lead to the family not wanting me there..What the home health agency wants is different in what the family wants in patient care so there was a conflict on what I wrote on my notes..

If the home health supervisors were there with me with the family members, they would know what was happening..I am in the trenches and the supervisors are not..They are in an office building 25 miles away following rules and guidelines on what is right...They never stepped a foot in the home of my patients or met the family..

When the care that you render and your notes regarding that care differ from the plan of care (485), then you should write a separate communication note to the DOCS/Nursing Supervisor explaining what is going on. This keeps the supervisors informed and allows them the opportunity to intervene or at least be aware of what is going on in the home. They don't have the opportunity to correct anything or provide any input to the family, you, or the MD, if you don't inform them in writing of discrepancies. You have to be careful what you write on your shift notes versus what you write on the communication note, and both need to be done professionally. These communication notes that are written outside of the daily shift note are part of the record for that case. A lot can be done based on you providing your supervisors with these notes. If they choose to take no action, then you have proof that you did your job in bringing it to their attention. You can't force them to take action. That is the difference between supervisors who get involved with their cases and those that are more along the line of strolling around collecting a check and little else. You CYA with these notes whether or not the supervisors do anything.

[Devil_Duckie, LVN]

Yes, there are several methods of chart auditing utilized at the hospital I work at. We have a clinical unit educator on each unit that is responsible for all aspects of nursing education, including charting, preceptorships, scheduling for classes, and communication with the nursing staff re: new policies, changes in procedures, etc. She also randomly audits computer charting, especially with the newer nurses (new grads like me, who welcome any suggestions when it comes to documentation!!!) and notifies them when an item on the chart needs to be amended.

Personally, the only feedback I have gotten so far about my documentation (aside from the advice I received from my preceptor) has been regarding certain admission checklists and insulin co-signs. Our CUE pays very close attention to our charting and it's always considered a helpful and friendly reminder when she alerts us to a mistake. Also it helps that at our facility, we are allowed to chart within 24 hours.

Additionally, each nurse is responsible for four chart audits per year (one per quarter) including computer and paper charts. I think the system is working very well however some of the other (know-it-all types) nurses on my floor think it's silly and get aggravated when they get alerts about documentation mistakes. Personally, I like the fact that someone more experienced than me is willing to help me with my inexperienced charting skills....

[Zookeeper3]

every chart every day, we even place "sign here" stickers to remind the docs where to place the signiture

[not now, RN]

We are assigned to audit one staff members charting. I think we have to do four charts every month on the same person (month after month) and go over any mistakes with them.

It's "not mandatory but will effect pay for performance at your yearly review" which means it's mandatory.