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help me fix this documentation issue

bernard11 bernard11 (New) New

about six months ago I had a patient that I distinctly remember seeing every wednesday afternoon. I remember this because the pt and his wife were very insistent on always having the same appointment every week. I am 100% certain that i never missed a weekly visit with him on wednesdays in the time he was under my care. He was eventually discharged to a SNF when he needed a higher level of care.

a few weeks ago my supervisor came to me and said that our finance dept had received a request from his insurance company to see any documented nursing visits from certain dates of one week in october. she said she went into the computer system and there was no note from that entire week. i double checked and my note was nowhere to be found. my notes from the previous weeks and following weeks were there, but not that one specific week. my supervisor went to the I.T. department to see if they could somehow find it in the system but they were not able to. the I.T. department said there was a big system fix/overhaul thing on that ONE wednesday in october and all of my notes from that day were deleted.

i'm worried that i could somehow be disciplined over this since it looks like i did not see this patient when i am certain that i did. there is even documentation from the pharmacy we use that i had called in and faxed a script to them for a new medication for this patient on this specific date, so i do recall some of the visit's details but obviously i can't remember his vitals etc. from six months ago. my supervisor is very supportive and said she would work with me to do like a 'visit summary' of sorts to recall anything i can remember from that visit and present to the insurance company in lieu of the standard visit documentation. when i asked her why the insurance company would be looking into this, she said they do random quality control checks.

is there something more i can do to remedy this? or am i getting panicky over something that will be easily be settled when my supervisor and i write out the visit summary and provide proof from the pharmacy that i did request new medication for this patient? i'm thankful that i at least have some kind of back up from the pharmacy.

Rewriting the nursing notes for that visit, as best as possible from memory, annotating "reconstructed" at the top of each page, is what agencies normally have the nurse do. You annotate the note to differentiate it from the original, should the original be found, so that you can not be accused of attempting to be paid more than once for the same visit. Beware of the agency that frequently loses your notes.

have you seen this as an acceptable replacement? could a nurse ever be disciplined through the BON for this? or am i just being paranoid as something this serious has not happened to me before?

i have been with this agency for 1 1/2 yrs and it is the first (to my knowledge) that they've lost my documentation, but other nurses have said they've had it happen to them. i actually have taken a job somewhere else and just put in my notice.

It is probably just a coincidence that they lost this note. If the agency was going to go to the extreme of reporting you to the Board, they most likely would have "lost" more of your notes to strengthen their case. Rewrite the note. Should anything come of it, simply report that you turned in your notes as usual, (you were paid for the date weren't you?). Now, if they did not pay you for that visit, they could make the accusation. From your description, it does not sound like this is the case here.

thanks so much for your insight. i feel better.

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