Got citation on my documentation by department of health surveyor...;(

merlee · Jan 25, 2012

No one is going to suspend your license for a discrepency in an Oasis. If I could, I would personally come to wherever you are and slap that nurse for handing you that line of bull$hit. Truly. I simply don't understand why people do those things.

If the pt stated that she has no pain at the time of your collection, well, she had no pain. The question might lie in whether she was taking pain meds and if they were effective. There may be a slight difference in no pain and pain is controlled w/current meds.

Please let your agency handle this, and calm yourself.

And trip that idiot the next time she walks past you.

umharhar · Jan 25, 2012

Thanks merlee!!!

You don't know how much your reply helps my troubled mind...

My ultimate goal is to get a job in hospital like any other new grad nurses and I don't want to add another problem on top of my lack of nursing experience...lol

And that person who told me that is not a nurse...she's one of office staffs...I asked her what does usually happen if you get a citation and she told me that...I guess she was telling me the worst scenario so I don't make any more documentation errors...? :uhoh21:

But I've learned that I should definitely work on my assessment skills and documentation. Thanks for your reply:redbeathe

caliotter3 · Jan 25, 2012

You are too new to all of this for you to expect perfection from yourself. As for the assessment, it is your assessment. What you observed at the time and how you interpreted your findings. Unless something grossly out of whack, they can not fault you for what you assessed at that point in time. If her temp was ....., it was ...... If she stated she had no pain, then she had no pain. You should have more input about expectations from your boss as time goes on so you will feel more comfortable with what you are supposed to be putting on that document. The surveyor is not there every day, so they won't be able to fault you on your every day job. I would take my cues from your immediate clinical boss if I were you, and don't worry about what the surveyor focused on for this one shot.

Isabelle49 · Jan 26, 2012

Don't lose any sleep over it. When you assess a patient for pain, there may be no pain in that moment. There was a real good article on pain at Medscape that taught me quite a bit (wish I could remember the title), but anyway, it discussed problems with pain assessment in that when that question is asked patient response is for that time only. Further the article explained how pain should be globally assessed, i.e., Do you have any pain while in bed, upon awakening, when rising out of bed or standing from a seated position, etc . You'd be surprised how specific we need to be when assessing pain. My patients often respond 'no' when I ask if they have any pain and then when I ask more specifically there is pain with certain activities. There is another good article at Medscape that discusses the increased rate and risk of falls with pain as a causative factor - it make a good point for teaching that I frequently use. Good Luck to you, you'll do great!

umharhar · Jan 26, 2012

Thanks Isabelle49

Like you said, globally assessing pain was what they wanted. I didn't ask those additional questions like 'do you ever experience pain? how often? what makes it worse?' kinda stuff that are right below the pain question on OASIS. The office staff said the surveyors said its like I didn't do assessment at all...so that comment got me pretty frustrated...;(

And she also said I didn't write down one of her allergy...so that's pretty big deal too...

But I did learn from it so that I ask my patients every single questions on OASIS.

I just hope nothing happens from this experience though...

Isabelle49 · Jan 26, 2012

It's a learning experience, enjoy!

RachRN66 · Jan 27, 2012

I've been a home health nurse for a long time and the oasis question deals with pain and/or the ability to perform normal activities. A patient may not have pain when you are assessing them at that moment because they are laying in the bed, or laying on the couch in a nice comfy position. But as soon as they set up or move they get pain in their back etc. Now if that pain in the back prevents them from getting around the house and doing their normal activities then it should be documented, even if at the time of assessment they have NO pain. Also I make sure I look at the med profile and see if they are on any pain medications. I ask them when the last time they took a Pain pill or "tylenol" for pain? How did it work for them, how often do they take it, what do they take it for. Often I get, "I don't have any pain but I take a pain pill at night to get comfortable and sleep". I document that. I document patient has no pain today but says they take pain pills at night for comfort/sleep. I also document on the patient that is laughing, smiling, walking around the house safely and pleasant, and says that their pain is 8/10 and they take xyz pain meds q 4-6 hours and appear to be able to function but still report a high pain level. Then there are the patients that go to the pain clinic and get multitudes of pain medications, take them as ordered, but still talk about their specific pains for more than 15 minutes during your visit, and if they show signs of having pain like facial grimicing, holding to the couch in a gripping mode every time they have to move, and how they rate their pain scale.. is the pain throbbing, constant, intermittent, aching, burning, sore etc and what they do to relieve it. I also document interventions around pain and pain medication. Like instructed patient to try heat to arthritic joint, or visual imagry, or journaling about pain, or taking the medication (if they can on schedule) before the pain gets so bad the pain pill doesn't seem to help. Even if the patient says they have NO pain when you ask, you sometimes have to dive in further and assess the bigger picture.

Isabelle49 · Jan 28, 2012

I once worked with an RN who refused to globally assess her patients for pain. Every patient she did an OASIS on never, ever had any pain (per her statements). I think she felt like it was her fault or she was doing something wrong if they said they had pain, lol. I can honestly say that I have pain somewhere every single day, it may not last long, but it's there and I'm only 62.