Ok! So, I have been in health care over 20 years now working in Major Hospitals as Nursing Assistant and now for 5 years have been working as an LPN. I currently work in a LTC facility with Rehab and just left a facility that was completely Rehab but downsized and went to all RN's.
The issue, I have been an old school documentation kind of person well this facility I worked for all Rehab constantly was teaching us how to document for today's Nursing and for Rehab purposes for payment reimbursement for Insurance. Well seemingly what I learned there for documentation the floor Nurses I work with now are familiar with the same kind of documenting. I learned that documenting
John Doe is A&O X3 speech clear, able to make needs known, lungs clear, abdomen soft and supple with no guarding present. skin warm and dry, etc etc. But, with it being Rehab...we were always taught at the major rehab facility to chart the patient for example, John Doe ambulates independently with w/w and gait steady. Mr Doe requires assist with ADL's and minimal transfer of gait from sitting to standing.
OK!! The issue now at the new facility, even though several other nurses chart the same thing because they were taught the same......we are told the patient does NOT have a steady gait because they are here for rehab and that they cant have a steady gait because then insurance looks at that and states "why is that person here if they have a steady gait." Well, for arguements sake, all the nurses have been arguing this fact because for one, the persons admitting diagnosis is not for "unsteady gait" they are admitted for PN, COPD, Hip Replacement, MRSA, etc...AND if we chart that they have an "unsteady gait and that they are ambulating with w/w independently then they loose balance and fall, why were we letting them ambulate independently with a w/w if they already had an unsteady gait. They are not here for gait, they are here to recover from PN and are weak not here for gait purposes. SO, our thing is if we chart that they have an unsteady gait and are independently ambulating and fall, why did we let them ambulate ind. in the first
Well, now our MDS Nurse has taken it upon herself to "Fix" the charting of other Nurses...................UH!!!!!!!
Please...........some help and knowledge from some others of you out there in this crazy health care world
Now that we are all having a fit about this whole steady unsteady thing.....another Nurse is "fixing" other Nurses charting!!!!! Grrrrrrr
Only the person who did the charting can alter the charting. If a RN must sign behind a LVN, then they MUST make their own notation if their assessment differs from that of the LVN and put their name to it!!!!!! Highly illegal to alter anyone else's documentation. If they are worried about getting paid, that is simple to fix. Just chart either pt stated weakness or observed weakness, but observed steady gait. And I agree......do something to stop this because Medicare does NOT mess around with false documentation. Especially if it's to get paid.
RNwillie
7 Posts
Only the person who did the charting can alter the charting. If a RN must sign behind a LVN, then they MUST make their own notation if their assessment differs from that of the LVN and put their name to it!!!!!! Highly illegal to alter anyone else's documentation. If they are worried about getting paid, that is simple to fix. Just chart either pt stated weakness or observed weakness, but observed steady gait. And I agree......do something to stop this because Medicare does NOT mess around with false documentation. Especially if it's to get paid.