How serious!

[Jeffersong]

I have been working as a visiting nurse. Somehow I forgot to sign my name(and RN) on the nursing record sheet which will be submitted to relevant insurance companies for payment. I did all the assessment and intervention on the patient but I realized today that I didn't sign my name but faxed the record to my agency. It has been almost two months now and haven't heard about it from either insurance companies or from my agency.

Was it a serious mistake that I forgot to sign my name on the assessment sheet?

Does it often happen in hospitals when you have a loads of work and forget to sign your name on the report?

I am a little concerned. I would appreciate if anyone could shed some lights on it and personal stories.

Thank you.

[classicdame, MSN, EdD]

rules probably differ between acute care and your practice, but in a hospital it basically means it was not done. Might not get reimbursed for that day, but if the payor does not request the chart it might slide thru. Don't beat yourself up. Just learn from it.

[Jeffersong]

Thanks Classicdame. I won't forget this incidence. It wasn't an acute care but just a routine assessment. It had pt's signature if that makes any difference.

[mamamerlee, LPN]

I wouldn't worry about it - if someone catches it, they will simply ask you to sign the original and fax it again, or come in to the office to sign it. Did you get paid for the work?

The patient's sig confirms that you were there on that day.

I was a home health nurse for many years, and when we went to a computerized system, there were not many ways you could go back and do something over, but you could amend a note, or make a late-entry.