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Inappropriate documentation?

So back story, working in LTC and had someone that’s a daily fall, fall on my shift and become hurt. I completed our fall protocol, and notified all correct people. After following up with hospital to check on admitting/sending back patient I put in following note:

”resident to be admitted to BLANK hospital with current diagnosis of BLANK”
 

I was reprimanded for doing so. However, we typically are expected to follow up on if our patient is to be sent back or admitted, along with placing a note. Now I’m being told I improperly acted because I should’ve kept that info privately to our DON. 
 

Opinions?

28 minutes ago, Emily Simmons said:

So back story, working in LTC and had someone that’s a daily fall, fall on my shift and become hurt. I completed our fall protocol, and notified all correct people. After following up with hospital to check on admitting/sending back patient I put in following note:

”resident to be admitted to BLANK hospital with current diagnosis of BLANK”
 

I was reprimanded for doing so. However, we typically are expected to follow up on if our patient is to be sent back or admitted, along with placing a note. Now I’m being told I improperly acted because I should’ve kept that info privately to our DON. 
 

Opinions?

I don't think you did anything wrong. When transferring out a patient we all enter progress notes, and you only seem to have entered which hospital and DX or reason for transfer. 

I don't understand your facility procedures, and I find it very odd that only the DON should be made aware to where the patient was going to? That information should be available to oncoming shift and other care team members , so they can follow up and maybe provide the pt's family/health care proxy with answers. 

Hmm..

FolksBtrippin, BSN, RN

Specializes in Psychiatry, Pediatrics, Public Health.

Seems like an appropriate thing to document.

Is the facility trying to hide the fact that the patient had to go to the hospital and has a dx of BLANK?

Shady.

6 minutes ago, NewRN'16 said:

I don't think you did anything wrong. When transferring out a patient we all enter progress notes, and you only seem to have entered which hospital and DX or reason for transfer. 

I don't understand your facility procedures, and I find it very odd that only the DON should be made aware to where the patient was going to? That information should be available to oncoming shift and other care team members , so they can follow up and maybe provide the pt's family/health care proxy with answers. 

Hmm..

Okay thank you! In my eyes that is factual information of where she will be located if we need to follow up with family or to follow up for expected return. However, from their stand point because it pertains to the fall they say it doesn’t look good and doesn’t belong in the medical record for suing purpose? 

The way I see it, whether I write that sentence or not, if someone wanted to sue there is literally clear paperwork that says she fell, was admitted to the hospital (along with all the hospitals documentation on what diagnoses came about) and then the outcome. 

Just now, FolksBtrippin said:

Seems like an appropriate thing to document.

Is the facility trying to hide the fact that the patient had to go to the hospital and has a dx of BLANK?

Shady.

That’s how I feel! Like this is factual information, and a part of her health record. You can’t erase what happened by never mentioning it on the computer. 

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine.

The thing is, intentionally left clear "blanks" tend to get forgotten and unfilled. Later, if by any chance there will be an investigation, "blanks" turn to be big troubles. 

You couldn't have an idea what diagnosis the patient would be admitted. Yes, she fell. She could break a bone, could be found with UTI, with AMS changes, etc. Her admission diagnosis could therefore be very different from "fall at facility" and then the DON  would have to explain it. "Sent out with fall, admitted with UTI, later died in hospital from sepsis" - one of the most common bases for lawsuits against SNFs. 

Same goes about hospital. Patient could be considered for admission but was seen in ER and sent back, or family refused admission, or he was sent to different hospital 50 miles away for some reason. Even if the process won't be exactly about your SNF - there are currently multiple instances of hospitals being sued for refusing to admit SNF patients to reserve beds for COVID19 or private practices patients - still your DON will have to deal with people she doesn't want to. 

For the future reference, the rule of thumb: you can document FACTS ONLY. Not impressions, considerations, thinkings, etc., but facts. 

"Spoke with Dr. "X" over the phone, order placed for sending the patient in ER evaluation. Called Mrs. "Y" daughter and DPOA for update and permission to proceed at 0600 PM,  no answer, left message, awaiting the call back. No preferred hospital listed in the chart, awaiting DPOA call back to discuss preferences. Patient is stable, VSs are.... and followed as per protocol, pain 0/10, A, O x2 (baseline x2), bed alarm on, will continue to monitor". 

Edited by KatieMI

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro.

I took the OP’s use of the word “BLANK” was to avoid putting the real info on a forum.  Not that she put blank spaces or whatever into the legal document.  She said she made the note after speaking to someone in the hospital about what had happened post transfer.  

1 hour ago, KatieMI said:

For the future reference, the rule of thumb: you can document FACTS ONLY. Not impressions, considerations, thinkings, etc., but facts. 

I'm sorry but I fail to see where did the OP document non facts? The reason for the patient "s transfer was injuries sustained (the OP didn't diagnose the patient , only assessed the pt and determined they were injuries. Also, the transfer to location will be all over the transfer forms, nurses notes (I called and gave report to so and so from x hospital ED department. 

In my facility we would get in trouble if we didn't document the above things. 

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine.

11 minutes ago, NewRN'16 said:

I'm sorry but I fail to see where did the OP document non facts? The reason for the patient "s transfer was injuries sustained (the OP didn't diagnose the patient , only assessed the pt and determined they were injuries. Also, the transfer to location will be all over the transfer forms, nurses notes (I called and gave report to so and so from x hospital ED department. 

In my facility we would get in trouble if we didn't document the above things. 

Diagnosis of hospital admission was not factual. The OP documented the "diagnosis of discharge from SNF". Patient could be admitted for something which might be sounding completely unrelated like UTI or metabolic encephalopthy or severe anemia, not mentioning that he might be not admitted at all after being evaluated in ER.

Being one of quality benchmarks, the difference between "admission to ER" diagnosis and "hospital admission" diagnoses carries some implications for Medicare/Medicaid payments as well as abundant potential for lawsuits, both against the facility and providers. 

As an RN cannot diagnose patient, it would be appropriate to write "called report with Mary Doe, ER RN, patient is going to be admitted to ER hospital (name) for evaluation after fall". 

And, yeah, the DON in question seems to be a little too private and a little too free with her powers, to say the least. 

3 hours ago, KatieMI said:

Diagnosis of hospital admission was not factual. The OP documented the "diagnosis of discharge from SNF". Patient could be admitted for something which might be sounding completely unrelated like UTI or metabolic encephalopthy or severe anemia, not mentioning that he might be not admitted at all after being evaluated in ER.

[...]

As this note was written after contacting the hospital, how was it not factual?

9 hours ago, Emily Simmons said:

So back story, working in LTC and had someone that’s a daily fall, fall on my shift and become hurt. I completed our fall protocol, and notified all correct people. After following up with hospital to check on admitting/sending back patient I put in following note: [emphasis added]

”resident to be admitted to BLANK hospital with current diagnosis of BLANK

[...]

 

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine.

55 minutes ago, chare said:

As this note was written after contacting the hospital, how was it not factual?

 

ER was called to admit patient who fell. The diagnosis of discharge from SNF was "fall". It is not given that the patient will be admitted to ER with "fall", it depends on the diagnosis of admitting ER physician."Fall" by itself doesn't justify inpatient admission, only "observation" and not always even that. So, the ER doc will beef case up for admitting provider so that patient could stay and hospital will get paid. Patient therefore will be admitted under some other diagnosis. This is providing that there will not be anything else. 

By itself, it means nothing for nurse from SNF. But, suppose, patient was frail 90 years old who fell, was sent to ER and there found to have aspiration pneumonia and sepsis as well as UTI. She will be admitted for aspiration pneumonia, UTI and sepsis, of course. 

After this, the following might happen:

- administration of SNF would be deadly upset with patient's PCP  who "missed" UTI and UTIs incidence, as well as infections requiring admission are their quality benchmarks which will look worse; 

- the PCP will get "diagnostic discordance" paper from Medicare/Medicaid, especially if this is not the first time. It is his benchmark; he will have to spend time filling it up and become deadly upset too; 

- and there will be irate family of the patient blaming everyone (but the PCP and hospital attending fill go toward shooting squad first) for "missing" pneumonia, UTI and sepsis. Especially if they were initially called by SNF RN and told about "just a fall" and "just to make sure your mom is okay" and the first thing they know in hospital is that mom is in ICU. 

This is why "fall" and everything else a patient sent out from SNF should not be written as diagnosis ("sent for...") but merely as "patient was sent to ER for evaluation due to/after...", with the last vital set and assessment data included. 

Edited by KatieMI

I just wanted to recommend that you if your user name is your real name, you change it to something anonymous. Good luck. 

6 hours ago, KatieMI said:

ER was called to admit patient who fell.

I read it as OP called the ER to see if the patient would be admitted or sent back to the SNF and was told patient was admitted to "xyz hospital" for dx of "insert dx given by hospital". Not that OP was documenting and diagnosing the patient herself. IE the nurse at the hospital updated OP that the patient would be admitted and what the admitting dx was.

If the patient fell in the SNF due to a dx missed by the PCP that is not OP's fault. She's doing the job she's supposed to do. She followed up on the patient and documented the information she was given by the hospital. If the case ended up in court, she did her job. Assessed the patient post fall, sent them to the ER for further evaluation, the ER admitted them for x dx and she documented the follow up..... OP's job done!

RN-to- BSN, ADN, RN

Specializes in SCRN.

It's not wrong to follow up on the patient, but I think "to be admitted with a diagnosis" is not a fact. The medical diagnosis for admission is not clear until patient is seen by admitting MD. The documentation should say the narrative of the follow up phone call as previous posters pointed out.

Good learning situation, though.

On 7/14/2020 at 7:00 AM, Emily Simmons said:

”resident to be admitted to BLANK hospital with current diagnosis of BLANK”

Nothing wrong about this type of note, although I would write in a way as to be clear that it is reported information: "Phone call to [facility] to check on resident. Per ED RN, resident to be admitted for dx of [primary admission dx]."

On 7/14/2020 at 7:00 AM, Emily Simmons said:

Now I’m being told I improperly acted because I should’ve kept that info privately to our DON. 

Sounds like they need to make up their mind about their documentation policies. A good, neutral-pleasant response to this type of thing (and many other interesting confrontations) is, "Where can I review that policy so I know what to do going forward?"

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