Documentating what you have not witnessed question

[AtlantaRN, RN]

Regional chart auditor is at my office this week. We have been instructed to not only document "spoke with attending who agrees with hospice admission," and "spoke with medical director who agrees with hospice admission," (those i have called myself and INDEED are able to document as such). TODAY we are instructed to document that "attending and medical director have spoken....and are in agreement". Why would I be asked to do such a thing. Isn't enough that I have spoken with attending and Medical Director?

Anyone else run into this?

Thanks!

linda

[Whispera, MSN, RN]

I haven't run into it, and think it isn't something that should be done. If you weren't there when they talked or didn't hear them talk, or one of them didn't tell you they talked, you have no way of knowing that they talked and it would serve no purpose AND would only be an opinion.

[shrinky]

I agree that I would not document something you did not know as fact. I have not heard this but we do document after we speqk with each one that we received a verbal order for cert from each and each of them have to sign the cert. Don't know how I would know they spoke with each other unless I was present. Good luck and let us know what happens.

[Whispera, MSN, RN]

What would happen if they hadn't talked to each other and one of them was upset about something and you had said they talked to each other....who would be in trouble? You!

[AtlantaRN, RN]

My manager misunderstood. We are being asked to document that WE have collaborated with attending and medical director. That is fine. I'll document what I have witnessted.

linda