Oasis help

Wooh- I've written this reply 4 times now and it keeps getting deleted. So If it shows up randomly later with 4 replies, I apologize. The patient is on so much pain medication that the PCP was not willing to alter the dose. Said if her pain was intolerable to go to ER, she refuses. She was pretty out of it during my visit, nodding off and such. I explained the pain scale in detail and her answer never changed, so that's what I documented. I tried to resolve the issue unsuccessfully. And in my personal opinion, more pain meds would have definitely put her at a greater risk in general since she was so out of it. This was also documented as well as the contact with the MD. It's hard not being able to help, but I'm learning that sometimes all the effort you put in does not always yield a positive result. So far I have probably 11-12 hours of time invested in this patient with all the follow up calls and revising of the document. I've calculated how much per hour it would equate to and it's under 4/hour. I just might not be cut out for this.

NakiaRN- I totally understand correcting inconsistencies, that's ok with me. I knew I would need some help in that department and I would welcome the help if they offered to walk me through what's being changed and why; that way I can avoid making the same mistakes again. Unfortunately I was unable to get in contact with the specific QA nurse who made the changes as she was not in our office branch

I am learning quickly that this is absolutely true. I used to gawk at the posts about "I'm going to lose my license!" But now I get it, in this field of nursing, I would definitely be the first one thrown under the bus if the crap hit the fan.

Thanks for the advice. I go in tomorrow, hopefully after a talk with the QA people, they will explain to me why it was acceptable for them to change my assessment data. I think many of the nurses with this agency just go with the flow. I don't think it's going to work out with me because I'm just not willing to have my name attached to documents that are altered as they see fit. I have no idea why they changed the pain score, my guess would be because the pain was unable to be controlled. I called the doc about the pain and they were unwilling to up the dose of her medication due to the fact the patient is on an extremely high dose of morphine already as well as other pain medications and it just wasn't safe. So maybe it looked like we did not address the issue. I really don't know, I love home health but I think my days are numbered.

The manager is not helpful, he says the QA staff know what they're doing and to just redo the form.

Hi, I just started as a new home health nurse and am getting used to the oasis documentation. The company I work for has QA staff that go over our documentation to check for errors. The QA person went over my first OASIS and found a few errors. They corrected the errors and also changed some of the data that I collected. I understand the need to correct errors, I am new and got 2 days orientation so it's not surprising that I made some. However, I am uncomfortable with them changing my documentation and then being expected to sign. For example, the QA guy changed the pain level from an 8 to a 4. Also they changed some of the ADL questions. I've redone the oasis 3 times now and they are asking me to revise it yet again. They shredded my original so the only thing I have to go on is the form they revised. I don't know how home health works, but it just seems very strange to me, especially since they want me to sign the form after they've made changes that differ from my initial assessment. I finally got fed up and said no, I will not be revising and signing my name to the form because it is not reflective of my initial assessment. To me this seems borderline medical records fraud, but then again I am new so what do I know? Please tell me what you think.