Medication Charges

[asilmk]

We have come up with a new problem at our hospital. If a med is not signed off on the MAR, it is not considered given, therefore the hospital cannot charge for the med to avoid medicare fraud issues. It used to be good enough to document IV fluids, IV drips, and PCA use in our nurse's notes or on the PCA flowsheet (as appropriate.) Now, when a pt is transferred to the floor, another facility, or home we have to copy every MAR page and put it in a bin for pharmacy to come up and count the # of meds signed off and to make sure the count matches the # of meds charged out from the pharmacy. (Yes, we still paper chart and pharmacy brings our meds to us instead of us getting everything out of the pyxis.) In some places we are double and triple documenting. We still have to put our IVs and drips on our notes but also on the MAR. Nurses notes are considered "nurse to nurse communication" and not a "legal document for medicaiton charges." It is very annoying to have another step added to our transfer process and I get tired of the "oh, the nurses will do it" attitude. Also, I wonder if they can tell us that our nurses notes are not legal documentation for one thing, will it be legal documentation that we really did call that MD or of vital signs? I think we're setting ourselves up for problems if we're able to pick and choose which parts of the nursing notes are valid legal documentation. Also, anytime we double document it is just begging for trouble. How are medicines charged for at your facilities? Any suggestions for how to handle this? Thanks!

[TazziRN, RN]

Nurses notes are indeed considered legal documentation. You may have to go through the extra step of signing off the MAR, but the NN are legal.

[GoldenLove]

ALL nurses notes are legal documentation!! That is the first time I have ever heard "nurse to nurse communication"...PFFT!

[TrudyRN]

I think meds should be signed off on the MAR anyway. Forgetting is understandable to a point - like if a true emergency arises. But why are the meds not being signed off on the MARS? That's what they're there for, right?

What I would object to is having to also write in the NN that I gave certain meds, IV's, etc., unless I was doing it to cover my rear. Don't you have PCA's, IV's, etc. on a flow sheet or on the MAR? Why must you double chart these?

And I don't know why nurses should have to be copying the MARS. Let the Pharmacy or Med Rec staff or your unit clerk, if you even have one, have access to them and let them copy them. Or Pharmacy can do whatever counting they want to do right there on the floor - as long as they keep out of your way. This is where your DON needs to go to bat for you. How dare anyone expect you to have to do extra work? What will they add to your workload next?:angryfire

[GingerSue]

ALL nurses notes are legal documentation!! That is the first time I have ever heard "nurse to nurse communication"...PFFT!

same

I never heard of documentation as "nurse to nurse communication."

Nurses notes are legal documents is what I see in my textbooks.

[meandragonbrett]

Nurse to Nurse communication would be REPORT! Our meds are charged via the Accudose

[asilmk]

Thanks for the posts. We are a small facility and don't have a unit clerk all the time. We never have a CNA. It's really hard when I'm trying to be a one person show and it really is a big deal when they tell us now we have to copy MARs too. We do have PCA flowsheets, but that is part of what's considered "nurse to nurse communication" along with the nurse's notes. As far as our DON stepping in....yeah...I won't hold my breath.