Physician-centric?

[KateRN1]

Okay, so I just finished the Blueprint for OASIS Accuracy seminar and something dawned on me today. We're going through the POC synopsis, section M2250, and I realize that so much of what we can "claim" depends entirely on the physician returning communication regarding the ordered plan of care. And that technically we are supposed to be either obtaining verbal/phone orders or waiting for a signed 485 before we go back to the home, etc., etc. Well, we all know how often the physicians return a call or fax in a timely manner, and generally we do what we need to do for the patient. But I'm freaking livid now that basically, CMS paints us a handmaidens to the physicians. We can't even take credit for assessing a patient's pain level unless the physician ordered it. What the h3ll kind of Barbie do I look like? There is no notion of collaborative practice whatsoever allowed in this entire industry. It all falls to "the physician-ordered plan of care." Hello, it's more like a physician-approved plan of care.

I don't know why this suddenly dawned on my today and why it's gotten under my skin so badly, but I am irked. Really, really irked. This is what's wrong with healthcare in America--putting physicians in charge of everything, whether they want it or are qualified for it. We will never move forward until health care is a collaborative effort between physicians, nurses, therapists, and pharmacists. I can't think of a single physician I have ever known or heard of that is a master of all these disciplines and is qualified to *order* rather than *approve* of each disciplines "recommendations."

Who's with me?

[4evernrs]

Very well put!

[caliotter3]

I agree, very well put. I'm nothing but an LVN, but I find myself sending forward "suggested" orders for signature quite frequently due to circumstances. Nothing would be accomplished if I did not do so. I'm disgusted. What incentive is there for an RN to become an NP even?

[Willow Moonsidhe]

I got chewed out today by our DoN for putting a piece of petroleum gauze and kerlix over a 18 cm X 11 cm diabetic venous ulcer until I could get orders. Is this really considered practicing outside our scope of practice. It takes forever for a doctor to respond to calls or faxes if they ever do. We even get routed to the patient medication request lines when we ask to speak to another nurse about a patient. That happened to me today with a blood sugar 490. I get so tired of the non response.

~Willow

[spejsa]

I totally agree here! I hope that I can figure this stuff out soon. I start a new agency soon. this one is really a mess, hoping the next one is a little better. Sounds like it's bad everywhere though

[HmarieD]

In total agreement! What's even worse, those measures will be publicly reported, but it will not be explained to the public that us being able to answer in the affirmative depends on the MD doing what they are supposed to do. It just looks like we're slackers who aren't taking care of our patients! So frustrating!

[KateRN1]

That's exactly my point, HMarieD! If we are going to have to accept the results, make it a situation where we have some control over it!

[annaedRN, RN]

Ditto to all the above!!!! Very frustrating!! especially when we are the ones "suggesting" to the docs what these patients need to have on their plan of care!! It does not matter how much we document what we assessed, called about, informed the doc of - if the doc does not get back to us timely and thus not on OASIS...it makes it look like we are not doing our job! Sad reflection on society's perception of nursing...

BTW, how did the COS-C exam go Kate??

[Willow Moonsidhe]

I sent the below letter to the state boards and I am going to try and find out were we stand on this issue. I will let you all know the reply.

I have a question I need answered from a source that I can trust. I started working in Home Health and there is a severe problem getting physician orders for wounds or any orders at all. When we call a physician's office; we get the patients request voice line. Most of the time when we are not even allowed to speak to the physician's nurse so he of she can relay a message for us. It usually takes two to four weeks to get orders back from a physician. Are we covered in these cases to clean a wound with normal saline and cover it with a simple petrolium gauze dressing, to prevent infection. I have been told this is considered practicing outside our scope of practice. I would like to hear from you on this matter. It is sad; and definitely a statement to the state of nurse physician relationship today and health care in general. I just need clarification on this issue please. Thanks so much.

Sincerely,

~Willow

[KateRN1]

Willow, I've had the same thing happen to me--accused of practicing outside my scope when applying a non-ordered dressing. On look back, though, it think it was more an issue of how to capture payment for the supplies if they were not ordered by the physician. I don't think it was ever outside the nurses' scope of practice to assess and treat a wound with items that can be found in any drug store. Leaving the wound open to air and infection would be negligence, would it not? What am I supposed to do? Stand guard at the bedside for two weeks until someone calls back and approves my wound care? I think not. Always act in the patient's best interest and you should be fine. What's in the agency's best interest is not always the same thing.

Annaed, the COS-C exam was tough. Before the seminar, I was thinking, "Eh, open book. How hard can it be." The answer is: very hard. I think I did okay, I think I passed. Pretty sure. However, if I had not done the 2-day seminar, I would have failed for certain.

I remember someone here posting something like, "OASIS isn't that hard, all you have to do is answer the questions." I assure you, if you feel that way, you do NOT have a good grasp of it at all.

I learned enough in the first ten minutes of the seminar to justify the cost. I discovered about ten different ways we are losing money because we're not capturing data correctly and it's affecting our HHRG scores. But I also found several things we're doing that are not in compliance, so that's not going to make me a poplular person come Monday morning.

For anyone planning on spending a good portion of their career in Home Health, I would highly recommend any and all of the seminars by OASIS Answers to further your understanding. Check with your state's home care association if they're not already, ask that they sponsor the seminars. It's sooooooooo worth it.

[Willow Moonsidhe]

My DON got so upset that I felt she might actually call the boards and accuse me of practicing outside my scope of practice. I am going to a different agency because I feel like her and one other RN are doing drugs, alcohol or something. She is angry all the time and to begin with she was writing all staff meetings as a verbal warning and standing at the head of the table yelling at us for 2 hours. I told her I had never had to sign a verbal warning at a staff meeting in my 25 years as a nurse; to discuss what we need to be doing and that I did not like that because it made me look incompetent to Corporate. She stopped that and now she tears all my charts apart for 2 hours in front of everyone; even the office staff, social worker and aids. I have only been in HH since Feb 1st and had 1 week and 2 days orientation. Had to do SoC's, RoC's, Recerts etc. So I made some mistakes to say the least. I found out our company has a wonderful video series on Oasis so I have been watching those and like you found a lot of things I was out of compliance with.

The other RN called me in front of a patient and yelled at me on the phone on my weekend off for 30 minutes. I reported it and she came to the office saying she was outside talking to me when the patient never wants her back at the home. But she accused me of all kinds of things I have not done. So I quickly became the bullied black sheep. It makes it miserable to go to work. This girl takes Hydros and Percocet for a back injury and had that dissociative behavior pattern like a drug addict. Best thing I decided was to get a job give notice then leave. Now they are discharging all my really sick people on medicaid with no agency that takes those but ours. They even accused me of making up a 18cm X 11cm wound; so I got a photo release signed and took a picture of it for the chart.

I am just praying the other agency will be different.

~Willow

[spejsa]

Thanks for the info! I really want to attend one of these seminars. I asked my agency if they would pay, but they would not. They said our corporate was doing training sessions once per week and I could come in at 8:30 AM on Wednesdays for the training... WHat I heard from staff that did come in, it was worthless...