I think this might be illegal!

[Oasis help]

Hi, I just started as a new home health nurse and am getting used to the oasis documentation. The company I work for has QA staff that go over our documentation to check for errors. The QA person went over my first OASIS and found a few errors. They corrected the errors and also changed some of the data that I collected. I understand the need to correct errors, I am new and got 2 days orientation so it's not surprising that I made some. However, I am uncomfortable with them changing my documentation and then being expected to sign. For example, the QA guy changed the pain level from an 8 to a 4. Also they changed some of the ADL questions. I've redone the oasis 3 times now and they are asking me to revise it yet again. They shredded my original so the only thing I have to go on is the form they revised. I don't know how home health works, but it just seems very strange to me, especially since they want me to sign the form after they've made changes that differ from my initial assessment.

I finally got fed up and said no, I will not be revising and signing my name to the form because it is not reflective of my initial assessment.

To me this seems borderline medical records fraud, but then again I am new so what do I know? Please tell me what you think.

[itsmejuli]

Sounds sketchy to me too. What does your manager say?

[Oasis help]

The manager is not helpful, he says the QA staff know what they're doing and to just redo the form.

[silverbat]

RUN!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Documentation should only be changed by the original nurse. Oh yeah... FRAUD!!!

[MunoRN, RN]

What was their reason for changing the pain score?

[kiszi, RN]

It's a common practice, but the way they are going about it seems shady. In my agency, the QA nurses would leave a voicemail detailing exactly what was changed and why. Mostly to correct inconsistencies. We had the option to note that we reviewed the changes and agreed. If we disagreed, the assessment would be put on hold until a discussion was had by both parties and an agreement reached. You should have the option to keep your assessment as is if you believe it should be. Changing a pain score? No frickin way!

[toomuchbaloney]

Just say no.

Do not sign documentation that you didn't create.

Tell them to outline what needs to be revised and tell them you will do it. Do it straight away, before any additional patient care.

Home care agencies do this because it is time efficient for them. They don't really care about your license individually, as a general rule.

[Oasis help]

Thanks for the advice. I go in tomorrow, hopefully after a talk with the QA people, they will explain to me why it was acceptable for them to change my assessment data. I think many of the nurses with this agency just go with the flow. I don't think it's going to work out with me because I'm just not willing to have my name attached to documents that are altered as they see fit. I have no idea why they changed the pain score, my guess would be because the pain was unable to be controlled. I called the doc about the pain and they were unwilling to up the dose of her medication due to the fact the patient is on an extremely high dose of morphine already as well as other pain medications and it just wasn't safe. So maybe it looked like we did not address the issue. I really don't know, I love home health but I think my days are numbered.

[Oasis help]

Just say no.

Home care agencies do this because it is time efficient for them. They don't really care about your license individually, as a general rule.

I am learning quickly that this is absolutely true. I used to gawk at the posts about "I'm going to lose my license!" But now I get it, in this field of nursing, I would definitely be the first one thrown under the bus if the crap hit the fan.

[kiszi, RN]

I hope the meeting goes well for you. If you love home health, know that all agencies are not equal. A hospital-run hhc may have better organization and protocols, but you may already be working for one for all I know.

Thinking back to my hhc days, there were only certain items the office staff could change (OASIS items I believe) and get approval from the nurse and other items they would request that the nurse change. It was an efficient and well-thought out process and I was very comfortable with it. Sounds like a different situation here. If your gut tells you something isn't right here, listen to it.

[caliotter3]

Would suggest you feel it out for awhile until you can tell whether they are always going to attempt to run roughshod over your assessments. If things don't even out with time, definitely look for another agency.

[wooh, BSN, RN]

So maybe it looked like we did not address the issue. I really don't know, I love home health but I think my days are numbered.

That's exactly what it looks like. Because the issue really hasn't been addressed. That doesn't mean the assessment data should be changed. That means the patient needs his pain addressed.