Falsification of medical records

[psunsg1975]

I work for a health insurance plan as a Director. A major requirement of the case managers is that they document the dishcarge plan for members in the hospital. While the nurses have documented "discharge planning discussed" there is no evidence of any specificity. We have changed the requirements for DC documentation, requiring the specific topics discussed or information requested, and have implemented audits to verify.

In my opinion, the nursing code which prohibits falsification of medical records applies in this arena no differently than in the hospital.

Case managers must adhere to strict documentation as must nurses in hospitals.

Falsification is grounds for discharge from employment.

Has anyone else run into similar challenges, and what actions were taken. Should these records be pulled, and compared to hospital records, it is likely the information will not match. Troublesome issue.

Thank you.

[I<3H2O, BSN, RN]

Why are you thinking that they are falsifying the information? If they are asked to do dismissal planning and they are charting it, then are they not saying they did that? I just do not understand why you would question the validity of their documentation....

[SummerGarden, BSN, MSN, RN]

OP: If you are their manager, you may need to think a little differently. First and foremost make sure to approach this entire situation positively because these are your own people. Maybe there is a good explanation for why you are finding (or not finding) the information you are looking for? Is it possible that there is a misunderstanding or miscommunication between your direct reports and whomever?

By the way, an outstanding forum for managers and those in management (I do not consider everyone in management a manager) to use on this site. The nurses that frequent the forum are great at giving good advice. Good luck to you.... I will see if this thread can be moved here:

https://allnurses.com/nursing-management/

[freefalling]

A comparison between your employees’ documentation and hospital records is a slippery slope indeed. You’re assuming that a hospital CM/SW documents the details of every conversation had with an insurance CM. In reality, with staffing as it is, facility CM/SW’s have as little time available to them as your employees. “Doing” overrides documenting any day, and specific details are undoubtedly left out of charting. They may even not have the chance to document that a conversation happened at all. No one wants to wade through a book written by the last CM with details like, “Call received from insurance CM Susan requesting verified demographics, faxed copies of discharge summary/instructions/new medications, patient’s home situation and what type of post discharge support will be in place, wanted to know if f/u appts have been made and when they are scheduled”. On a busy day, the best some may hope to get entered might resemble, “Choice form completed by pt, chose XYZ HHC, insurance authorization # 123456 for SNV x 3 obtained from Susan CM, faxed orders to XYZ HHC, await reply on ability to staff”. That’s it. Somewhere in there all those questions from the ins CM may have been asked and answered, but it’s not likely to be documented. Keep in mind that hospital CM documentation is for the benefit of the patient and hospital, not to show support of someone else’s work.

Short of recording every outbound phone call to a hospital (and then listening to them all), what type of an audit can you implement to verify particular questions were or were not asked of a hospital CM? It would be unfortunate if your employees were audited and potentially disciplined based on what a hospital CM did or didn’t chart that day. You are correct, it is likely the information will not match, but that’s not to say your nurses are falsifying their documentation. A more troublesome issue may actually be that, based on your employees’ streamlined documentation, you appear to have jumped to the conclusion that they are not being truthful, and are looking for ways to “catch” them by auditing hospital medical records. Perhaps they are also caseload-overwhelmed and would rather spend their time participating in the discharge plan itself than documenting every detail. Why so little faith in your case managers?

[d'cm]

I am not a manager but my work in an insurance company requires the review of other case managers documentation and I see falsification on a daily basis. In fact most of my career involved chart review and in my opinion anything that is not narrative, or written in the writers own words loses credibility but it certainly isn't limited to nurses. How many times have we seen doctors sign consents attesting they have explained all the risks for a procedure when you know damn well they didn't. Ultimately it is the organization's responsibility to create standards for documentation and formats for the documentation that facilitate clarity and truth, not some nebulous professional "code".

[toomuchbaloney]

hould these records be pulled, and compared to hospital records, it is likely the information will not match. Troublesome issue.

How are you anticipating that the case nurses reporting to you will maketheir documentation "match" the hospital records? Why are you assuming that the staff reporting to you are falsifying records, is there something you have left out?

[nurseprnRN, BSN, RN]

Suggest you ask your staff how to make it easier for them to document what you feel needs documenting. They might not know that their saying, "Discussed discharge plans c patient and family" isn't enough.

Can you say why? For whom? Is it a reimbursement issue? Have there been screwed up transfers? What makes you ask? Is some documentation specialist on your tail about this issue?

I agree that going into this discussion with the assumption that there is something fraudulent or deceptive going on is going to backfire on you in unpleasant ways you cannot begin to imagine, so avoid that as a conceptual framework.