Published May 20, 2002
In our agency, some nurses chart up to a month after a home visit. Our union rep told us today that this is illegal. She said we should be doing as in hospitals if we are doing it like this. In other words write "late entry." What do other nurses and agencies do?
Maybe I don't understand your question. You chart every visit. At one agency we had to turn the paperwork in by 8am the next day. At another we had till Friday pm to turn in paperwork.
nursesearl, BSN, RN
I'm sorry I didn't explain myself well. What happens is the nurse makes a visit, and just takes notes (not documentation), and then at a later time (sometimes up to a month or more) documents her visit in the chart. I found this very scary when I first started working here, but it's a something they have done for a long period of time. "Late entry" is not used, and we date it for the day that the visit was made. I have a feeling most agencies would not allow this. Thanks for any input.
CseMgr1, ASN, RN
How in the world does your agency do billing?? At the HHA I used to work, all visit notes had to be turned in by 8AM the next business day and audited by a supervisor, to ensure that it not only was a billable visit, but also met QI requirements. Those notes also generated payroll....no note, no paycheck!
OMG!!!!!!! I could never, ever, ever in a MILLION years wait and do my charting a month after the visit!!!!!!!!
I get confused if I wait til the end of the day. (hhmmmm..was the swelling in the right or left foot??)
hoolahan, ASN, RN
Same for us csemgr, no notes, no paycheck!! I worked in an agency where one nurse always charted late, even missed several recerts, they wrote her up repeatedly, but kept her b/c she is such a good nurse. Don't know if they ever got her to turn notes in, but sure seems like witholding a paycheck would do it for me. I can hardly remember things if I want until late in the evening to do my notes, I cannot even imagine waiting a month!!!
NRSKarenRN, BSN, RN
I can clearly see your situation. When I arrived at my current agency 3 years ago, I saw this problem. Nurses were so bussy seeing patients in one office 10-13/day "to cover all the referrals" that Recerts and 60 day summarys were not being documented---for 3 recerts! Only visit notes for that daywere performed, and rather sketchy at times. Some perdiem staff (working full time other facilities) who were the only RN seeing a patient, took as long as 2 weeks to get daily notes in.
This is clearly an administrative, computer tracking problem. Our data entry staff monthly get a report of all admitted patients to write up re-cert form. However they have to review the list against the computer records to see if patient was discharged, as the discharged clients aren't able to be deleted prior list printed due to antiquated system. Because of a lack of case manager ( nurses assigned just to cover case that day) Nurses had gotten so dependent on only doing recerts upon recept of this form.
Well, my prior experiences was more along the lines of Hoolahan and cse mgr: No notes and recerts in, no paycheck give to you on payday till completed---pay check handed to you by supervisor instead of payroll clerk with lecture. That only works if field staff are case managers. In this one office, many visits were being done by the per diem nurse of the day. Clinical manager was only looking to get visits covered, not if recert due as everything was paper and pencil system NOT using a computer spreadsheet to schedule from which could track when recert due.
So when OASIS hit, it has taken them a full year to get everyone to turn in paperwwork within 48hr window and perform OASIS recert in 5 day window AND TURN INTO OFFICE! They lost staff over this issue.
RE legality of submitting late paperwork: Depends on state law. I've seen nothing in Medicare rules that address this issue.
Do know that lawsuits have been filed by homecare nurses re paychecks being held and the nurses won---If they performed the visit, must be paid timely was ruling.
Will see if i can find out more info from DON.
I have to take a notebook into the home with me to jot notes. You don't want your delusional, paranoid and agitated patient to see you document that they are "paranoid, delusional and agitated" lol. Our notes are due weekly and we are going to "officially" start using our new notes next week (YEAH!). Now I can do charting by exception. I have a few patients who have minimal physical problems so this is going to be a great time saver.
Oh, and Hoolahan, I found out some info you might want. My QI manager talked to the OASIS specialist at the DHHS about the assessment questions in the OASIS form. We were going to use the new note as our comprehensive assessment and just develop a form with MO questions. We were told that the assessment is required to be integrated into the OASIS form in the areas related to that system. So much for "see note" If the assessment covers all systems, you do not have to do an additional progress note though.
We are on laptop and you have to document the same day or the laptop causes all sorts of problems. You can't backdate it. You have to send back to the agency via file transfer by 2am or the other nurses who transfer will not pick it up on their laptops. Than if they see your patient they will document over your note. It is a pain but prevents that problem. Our agency also gives us only 5 patients max per day and if you do recert or admit a patient it is counted as two. this gives you some more time. It never seems like there is enough time though.
Both agencies that I work for require that visit notes be turned in on a certain day of the week in order to get paid the next week. You do not get paid until the notes are turned in. But one of my employers will allow you to verify your hours over the phone if you are going to get your notes in late. I believe that charting a month after the fact is asking for trouble. An example: When I worked in a LTC, one time I did a weekly summary late. Later that day, the resident went home for a visit and passed away at home. I did not find out about this until the following Monday. The ADON was relieved to hear that I had used Late Entry as my charting had occurred after the resident's death.
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