insurance requested medical record

Specialties Home Health

Published

Hi, I had a patient with G tube and picc line. very resistant to care, noncomplaint; was refusing to go to PCP, so somehow i got order from surgeon to do tube feeding. on admission i taught him about gtube feeding, tube site care, and how to flush picc line. Next day i called him to confirm visit; pt refused feeding and cancelled visit beacuse he was feeling bloated with feeding; tried to inform the surgeon, but he didnot call back left message with his office; as instructed by DON from agency discharged the pt on next day; pt called on the weekend to on call nurse and reported he has infection at tube site. i called the pt and gave him option to call his surgeon, or asked him to go to ER he refused again; i told him that to resume care i need dr's order and approval from DON. long story short dr refused to give further orders when i spoke to him. i have everything documented.

we recieved a call from his insurance company and the don told them we will open the case again after getting dr's order. pt complaint to insurance company case manager that nurse is not coming to see him.

now the insurance company requested copy of the medical record and i am scared to death,

did it happen before to anyone that insurance requested copy of medical record?

pt has tricare insurance.

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You did your proper documentation so you should not worry. But I'll tell you one thing, I believe I would ask the DON to assign this patient to another nurse if they resume his care. After all, he complained about you with no justification, so the relationship is broken between you.

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Specializes in COS-C, Risk Management.

I'm still stuck on why the patient was discharged with obvious nursing needs? Did Tricare only approve a certain number of visits? Was the discharge scheduled? In either case, it sounds like the discharge was not warranted and the case probably should have been kept open, with authorization for further nursing visits requested from Tricare. You had an issue that had not been fully addressed. Just leaving a message for the surgeon without a call back or some kind of communication does not help the patient. Did anybody call the patient's PCP? Is the patient active duty or retired? If AD, then a call to the commanding officer would be warranted if the patient is non-compliant. If retired, then a call to the case manager would be advised. It sounds like there was not much follow-up with the care of this patient, unless there are details left out in your original post.

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i didnot know anything about Tricare case managers otherwise i would call them. after i left the message for surgeon i tried again x10 left 4 msgs with answering service. pt was noncompliant with everything refused to flush picc line, refused to flush picc line, refused to go to pcp, and refused to schedule appointment with oncologist. on my last visit verbally abused me and him and his roomate were so inaapropriate because they want me to do visits and do watever they want like to flush picc but dont touch peg tube; and most of the time they were not home either. i was told by DON to discharge him so i did i opened him on 4/22 DC 4/24 due to non compliant tried to reopen it again per pt request but dr didnt giv ethe order. and pt was not homebond either.

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Specializes in COS-C, Risk Management.

If the patient was not homebound, then it was an appropriate discharge unless Tricare has other criteria. The rest of it is a moot point. The case manager manager at Tricare may be requesting the medical record because of all the problems the patient had, or may just be conducting a standard utilization review. As long as you documented everything, you shouldn't have a problem.

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thanks KateRN1, yes i documented every thing including conversations on the phone with pt and surgeon. I hope i will not get into any trouble.

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Specializes in COS-C, Risk Management.

I don't mean to sound preachy, but let this be a lesson to you (and everyone you work with) about how important it is to document *everything,* even the least little things can add up and make a huge difference.

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I documneted everything, but i am scared, i dont want to loose my license. .

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