Nurses notes

[TXnurse87]

Hello all. Ok. I am needing some guidance or opinions of other nurses. So I have recently started this new nursing job. It's a third party company that deals with short term disability. Basically my job is to review medical information and see if the medical submitter supports approval of the std. We make notes about what the medical is and it's the diagnosis and rational on why we think it supports or does not support. My issue is that if I feel like the medical does not support and I explain that in my rational then my supervisor (who is a non medical person) decides if it does or does not as well. If they feel it supports when I don't they tell me to change my rationale to make it support. My issue with that is that I feel like they are making me change my "nurses notes" in order to how it supports. I think if the supervisor think it supports or vice versa then they should put in a note saying why or why not. The bigger questions is, are the notes I place really "nurses notes?" Sorry about being all over the place but I do need some help and guidance. If you have any questions please ask.

[LorenzoMastermind]

I think that if they are going to approve it based on what they think regardless as to what your input is then why even have to go through all the effort to plead your case just to be told in the end to go back in and change your response to make the verdict legit. Also I think they could be nurses notes I say look and question this further

[jadelpn, LPN, EMT-B]

Perhaps you could make general notes, NOT in the record, but general notes on why or why not you support, give to the person who reviews and adds their 2 cents, then make a final note in the record. Preliminary findings vs. final outcome. I would think that the supervisor is looking for key terms and phrases that is going to support your findings. Or I would like to think so, as otherwise, not sure what a non-medical person would really be "in the know" on any of this....or why a non-clinical person would even be the final say--sounds shady.

If you are making notes on the record, then the non-clinical person is having you amend your findings, hence amend your record, you could be held liable for any errors or if there is a problem with a legit claim that is denied, or a non-legit claim that is approved (and "my supervisor told me to change it" doesn't hold up well in most cases).

Make sure you have malpractice insurance.

[hope3456, ASN, RN]

Geez... Why do they even need you then? That sounds ridiculous.

[TXnurse87]

well we have to place our notes there. we cant make general notes and pass it to the supervisor since there are many of us for that one supervisor. Another reason i think they do that is since its computerized we have like 24 hours to make changes in our notes before they lock in and become permanent

[FineAgain]

Sounds like a racket to me. A typical insurance company racket.