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Discussion

Forgetting to chart?

So I had a new admission a while back and she had primary dx of CHF, I never got around to get a weight on her because she was on bipap and a little restless so I never did it (aides are really supposed to do the weights on every admission though but I get that im the nurse and need to make sure it gets done but had 8 other patients so stuff happends and I forgot). Anyways I guess I could have documented the patient refused at this time but I didnt so I never put an admission weight. So my manager calls me and tells me I need to come in to put in a weight or that the pt refused because the state is doing audits on charts for CHF patients. I told her I was not coming back in because I was already halfway home and was not gonna be stuck in rushhour traffic again. My question is can I get in trouble by the state itself for not documenting it or its more of nursing administration trying to scare me that there will be consequences? I feel there is more important stuff to get suspended or fired over and idk if this seems like one of those things. the manager just wants our unit to do well on the audits so me forgetting to chart the weight brings down our score or whatever the state grades you off of.

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    • Featured Replies

    OP:

    In matters such as this it's always best to look at things in perspective.

    Was the auditor right there asking where was the weight on this newly admiitted, fluid restricted CHF patient? If so, was the nurse manager personally at that time getting zinged by the auitor for your omission?

    If she was not, would it be too much trouble for her or someone to get the weight and chart it?

    With billions of dollars being bilked by providers each year from CMS either through omission or commision, you would think this small faux paux could be resoved without much ado and...

    WITHOUT MAKING A FEDERAL CASE OUT OF IT!!!

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    That is unreasonable to ask someone to turn around in rush hour to physically weigh a pt when a whole new team is working away. Or worse, come back to chart "refused"! When in reality they didnt refuse, but were not stable enough to be removed from o2!

    This is just weird! It has to be that some auditor is present or something. Even so, the only phrase i can think of is that is just "not reasonable". Who cares if your kid is sitting at the school steps waiting to be picked up...

    Is this typical the management style of your supervisor? Curious to hear how this played out.

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    • Experts

    Something similar happened to me. I was called at home to come in and "fix" something that could just as well have been done by the person on duty or by the supervisor making the call. Since I was a new employee at the time, I took it as an example of the caller exerting their authority and importance (same license but in a 'management' role).

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    Your manager could have easily obtained the weight herself or asked one of the aides to do it. Calling you at all was unnecessary. She could have waited until your next shift to discuss in person.

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