MED A DOCUMENTATION

[txdon]

The nursing staff has very poor documentation when it comes to Med A charting. Multiple inservices have been done, but apparently nothing has changed. Our facility requires documentation per shift. I need tips in helping staff understand the importance of this.

[RNLew]

Explain to the how much money is lost bc they didn't do their job. Usually upward of 10k a month on a partA. Get real numbers, have your MDS nurse explain what happens without the documentation. Usually people will do tasks when they understand the reason they are doing it.

[txdon]

Thanks for the advice. Besides having the MDS coordinator communicate the importance of documentation for reimbursment, do you provide your nurses with example documentation? I know some facilities use an assessment check sheet. Our facility requires a nursing note.

[Talino]

'in a nutshell'

[JTworoger]

The nursing staff has very poor documentation when it comes to Med A charting. Multiple inservices have been done, but apparently nothing has changed. Our facility requires documentation per shift. I need tips in helping staff understand the importance of this.

Hi bzyadon,

I understand your frustrations with documentation, especially when it comes down to Med A charting. My facility is also in the same ball park. I am the MDS Coordinator and have educated my staff on the importance of Med A charting, it just seems like nobody really cares anymore, or "doesn't have the time" to adequately document all that is nessecary. What we have done is created a "Med A" form for each shift to use on a daily basis. This form has just about the same areas as the MDS does, such as, ADLs, Cognitive status, skin issues, and other critical areas that needs to be documented daily on. We finally got our nurses to at least fill out the form, but they still hardly do nothing in the area of a narrative subjective/objective notation on the patient that you wouldn't see from just ticking boxes.

We have also started a "dot" system to remind the nurses they need to document on specific residents. To give an example: Residents that take antibiotics need to have their temp. taken every shift and documented in their chart with noted absence or apperence of adverse reactions with objective information documented that our treatment is actually getting better. If someone has pneumonia we want to make sure that at least their lungs sound ok and the antibiotics are actually working. We also have a fall/new admission dot to remind the nurses to document daily and every shift on this topic as well.

We also came to the agreement that if nurses where not keeping up with a vital part of "nursing," such as documentation, then they need to be written up, especially after all the policies that we have developed to help remind the nurses to chart.

I was a ER nurse for 3 years before taking this position and I have been to court before and let me tell you, I was glad that I documented as well as I did on that specific patient I had to testify on. I really don't think most nurses understand that and but they will the first time something happens and they have to be responsible when they get a subpoena.

Good Luck!

[RNLew]

I work for one of the largest LTC providersin the nation, so we actually have a specific skilled note form. However, I think it comes from Briggs. You could check it out. It has a portion that is checking boxes, which saves your butt on reinbursement and a narrative space at the bottom to CYA for the nurses.

I've also went through a rough spell with documentation, mine was pressure sheets, and fought this battle with my day shift for months. All I would ever get was victim type excuses, I've got too much work etc. So funny thing is that I ended up terming one of the day shift charge nurses over it. She was the worst one. Crazy part, after that, they tried the excuses for about a week and then next thing you know, they are all doing an impeccable job! I don't think it was the old "make an example" scenario I believe that one bad apple ruins the bunch! They all jumped on her ban wagon of excuses! Then convinced themselves they couldn't do it. Truth is, the one I got rid of really couldn't do it well, but the others were more than capable!

[mlolsonny]

We use EMR and ours uses Events as "to do" list for charting. We open a Clinical Charting Task event and put in what we want documentation on. Our nurses love our events.

[wyogypsy, RN]

I do think it helps to have some written guidelines on the form they use to chart on - trying to cover everything on a narrative note can be difficult, especially for a new nurse.

As for each nurse charting on each Med A patient each shift - that is overkill and not required. How about letting the nurses know that you would like the charting to improve, and to do this you will divide up the charting between the 2-3 shifts each day (depending on if you have 8hr or 12 hr shifts). This will give them a little more time to devote to those charts they do have for those days. I would be much more likely to chart well on 1/2 the residents on Med A than to have to chart on all of then every day. At our facility we rotate the days each shift charts on Med A - there is a schedule posted so each day you can look at it and see who you chart on for that shift, and we rarely have problems with it getting done.