Falsification of records?

caliotter3 · Feb 28, 2009

Just tell her flat out that you will not chart something that did not happen. She can do this if she wants to. You probably need to look for another job if you plan on not going along with this practice. There have been some other threads with this subject. You might want to look for them and see what has been said about the matter. To me, I see it as go along with what she wants or go elsewhere to work. This will not be the only time this issue comes up for you at this agency.

cookie102 · Feb 28, 2009

i believe the regulations state that if a patient can't be d/c'd with a visit the oasis is completed based on the information from the last skilled visit.

annaedRN, RN · Feb 28, 2009

Yep, what Cookie said. If a patient is discharged from/after a doctor appt, if wound care becomes unskilled, a patient refuses any more visits, or a variety of reasons...if a final visit cannot be made to do a discharge- the discharge oasis is done based on last SN visit - helps to be a visit by yourself or another RN

careforevery1 · Mar 1, 2009

At our agency we call this a non-visit discharge, the oasis form is a little different. I would make sure that you document the fact that no actual visit was made for the discharge and that your info is based on the last visit, if you don't have access to this non-visit discharge oasis form.

HmarieD · Mar 2, 2009

Actually, the DC OASIS in this situation must be completed by the last OASIS qualified clinician to have seen the pt, and is based on that visit. So, in other words, if an RN saw a pt with a Foley on 2/10, then an LPN saw the pt on 2/14, 2/20, and 2/24, removed the F/C one of these visits, the pt's functional status improved by leaps and bounds, and the pt tells you on 2/30 that they don't want the nurses to come anymore, the OASIS must be completed by the RN that saw them on 2/10, they would be noted as still having a Foley, and their functional assessment would reflect their LOF on 2/10. It should be noted in the narrative documentation that the OASIS assessment is based on the 2/10 visit.

This sucks for the agency, not being able to reflect improved outcomes, etc, but that is the CMS rule.

Super Nurse JoshuA · Mar 12, 2009

Thank you everyone answering for my question!!

dmdrn73 · Mar 15, 2009

Actually, the DC OASIS in this situation must be completed by the last OASIS qualified clinician to have seen the pt, and is based on that visit. So, in other words, if an RN saw a pt with a Foley on 2/10, then an LPN saw the pt on 2/14, 2/20, and 2/24, removed the F/C one of these visits, the pt's functional status improved by leaps and bounds, and the pt tells you on 2/30 that they don't want the nurses to come anymore, the OASIS must be completed by the RN that saw them on 2/10, they would be noted as still having a Foley, and their functional assessment would reflect their LOF on 2/10. It should be noted in the narrative documentation that the OASIS assessment is based on the 2/10 visit.
This sucks for the agency, not being able to reflect improved outcomes, etc, but that is the CMS rule.

I think in this situation if it has to be done by the RN who saw on 2/10 (our agency has the case manager do it if that 2/30 phone call is an LPN) that nurse should make a phone call so that the d/c OASIS info reflects what is going on now rather than what is going on from 3 weeks ago... That way you would be able to reflect the outcomes.

Doing the OASIS based on the 2/10 visit would only be needed if no one had contacted them since 2/10 and in this case (I am assuming it is a hypothetical one..) the patient was seen 3 times since 2/10 and there is documentation to reflect the fact that there is no Foley in place.

HmarieD · Mar 16, 2009

I think in this situation if it has to be done by the RN who saw on 2/10 (our agency has the case manager do it if that 2/30 phone call is an LPN) that nurse should make a phone call so that the d/c OASIS info reflects what is going on now rather than what is going on from 3 weeks ago... That way you would be able to reflect the outcomes.
Doing the OASIS based on the 2/10 visit would only be needed if no one had contacted them since 2/10 and in this case (I am assuming it is a hypothetical one..) the patient was seen 3 times since 2/10 and there is documentation to reflect the fact that there is no Foley in place.

That would be fantastic, unfortunately, it is a CMS rule that the OASIS assessment be based on the actual visit by the last OASIS qualified clinician to see the patient. Here's a quote from a CMS Q&A, only one of many that address this situation - "To be compliant with the discharge comprehensive assessment requirement, the qualified clinician that last saw the patient should complete the agency's discharge documentation as completely as possible, based on the patient's status at that provider's last visit. The clinician should note on this documentation that this is a situation of an unexpected discharge and the discharge assessment is 'based in the visit of mm/dd/yyyy.' "

To do otherwise would be fraudulent and counter to the rules established by CMS. As all of us in HH know, CMS makes some rules that seem to defy logic and are not beneficial to HHA's, but we must abide by them even when they don't make sense and we don't agree with them. You cannot base an assessment on a telephone interview as the info must be based on an actual visit and the assessment is to be based on a combination of interview and observation.