Is it legal to alter RN documentation?

[groverslisa]

I recently started in HH. To make a long story short: I discharged a patient for non-compliance and the pt stated she did not want further services, and her house is not very safe, ie: used needles everywhere after I gave sharps container to her, anyway, I documentated everything and filled out a discharge OASIS and gave it the office manager. About the time that person was getting around to putting in the computer, a business development coordinator decided to override my decision and not put the OASIS in. In fact, that person went to see her after I had 3 other nurses in with me to verify the noncompliance, and told put her back on service when she said she did not want it. I made phone calls to the doctor and reported it, but she has the right to refuse, right? My nursing documentation got shredded. Is this even legal? To top it off, I did not find out about this until after it had been done. When I confronted them and asked if it was legal, I was told that they know what is legal and what is not. I am convinced this issue is about money. They also tell me to round up on the pain scale, and to document things like incontinence if they pee when they sneeze. I know that is stress incont, and needs to be documented differently. I am not sure what to do.

[2008pn]

I don't understand how did they alter you documentation (R U talking about the shredding, cause I think that is something completely different)?

[caliotter3]

You need to get out of that agency, as quickly as possible. They are playing with your license. When, if, they get caught for their fraudulent behavior do you want to go down with them? Get another job. And completely document, for your own use, everything that happened and mail it to yourself, then don't open the letter. You also need to look into reporting this to the proper authority, as you don't want to be named in any fraud, waste, and abuse cases concerning this agency.

[groverslisa]

I am new to HH, and I am not sure how they did it, but they use a computer and I use paper and hand in the paper and they put it in the computer, instead of putting that she was discharged for non compliance and that she asked to be discharged, they put in that she wanted service and added a frequency for nursing visits and PT visits. The whole thing is confusing to me.

[BlueeyesRN]

We are getting ready to go paperless. I think that they do enter a lot of the information via some computer program. You company is doing some slide of hand conning work though. You can always call Medicare if that is who is the primary payer and file a confidiental report.

I have seen that being in home health there is some dirtiness that I think is not ethical and sometimes questionable.

My only other thought is if she had some type of physical decline ie., falls, muscle weakness, balance issues---a PT could do an OASIS without nursing present if she refused PT. This would not sit well and the fact that they did not try and explain or retify the issue is a big red flag. I know you too must be frustrated that your work was destroyed too. I always get copies of every OASIS and note--invariably months later you will find in QA they lost a note and then you have to write/pretend? that you remember the vital signs. I keep my own schedule and check each pt off as well. They may an try and say you missed a visit and they need missed visit note etc., so stay organized. Good luck! It's a hard job, but I love my folks. They're the best...so that helps considering the paperwork can kill and burnout any good nurse.

[HmarieD]

Just addressing the incontinence issue... incontinence is incontinence is incontinence, doesn't matter if it's stress, urge, around the clock, etc. I would document in my narrative what type and with what frequency it occurs, but for the purpose of OASIS, there is no gray area.

[Lorie P.]

agree with op, run as fast as you can! also be sure and keep copies of everything and document, document document !

[karmil]

I am SO GLAD I work for a fanatically HONEST Director!!!

[caliotter3]

I am SO GLAD I work for a fanatically HONEST Director!!!

That certainly does make things easier.

[BlueeyesRN]

I feel the need to correct something earlier I said....it was late when I wrote. I meant to say a PT can do an OASIS even if the patient rejects SN/nursing, not PT as stated.

I would leave this company. But as I said before as long as you are there keep copies of all communication/notes.

[ANTN84]

The HHA that i work for have a ''Quality Assurance'' department that reviews all things OASIS. We use a HI-TECH computer device and the info gets downloaded directly to the QA department who reviews and makes changes as neccessary. If any changes are made, they send us a message on our device letting us know of the changes made and reasons for the changes, we are also able to call them to discuss changes. I think that having the QA department is the reason for this company's great success in the area, they are rated number 1 in the are according to Medicare. I'm not sure of the legalities but so far it has proven to be non-problematic.

[nursencoder1]

Did anyone see that 5 nurses were arrested in Philadelphia for healthcare fraud? You will be held accountable if you participate in any falsification and the penalties are severe.