RN documentation dilemma -medicaid


I've been working for a home health agency on the east coast for about 4 months now. I worked night shift which requires me to do my nightly head-to-assessment and nurses notes. I chart-by-exception as my patient is on long-term care and stable for the most part. I got an offer to work days so my last night with that pt ended about 3 weeks ago. Today, my recruiter( not a nurse) asked if I could fill out a RE-CERTIFICATION FORM for medicaid services that is done every 60 days for the patient I no longer work with that should have been filled out weeks ago. He made a copy of my nurses notes from 3 weeks ago (where I charted by exception) and told me I could just transcribe the info over. I looked closely at the re-certification as I have never filled one out for them before. To me, it is very similar to an admission assessment form(asking in-depth questions about all the meds, past history, DX, TX, ect). I called him the following day and stated that I did not feel comfortable filling out this RE-CERTIFICATION FORM. I explained to the recruiter that because I chart-by-exception, transcribing what I documented 3 weeks ago over will not answer but a few questions. Furthermore, I have had 3 patients since then and can not remember EXACTLY what objective/subjective data I collected other than the fact that nothing was out of the norm. I told the recruiter, had he given me the documentation ahead of time or at least have let me know it had to be down, I would have written down details to transcribe over. I told him again, I don't feel comfortable with putting (whatever) down and he said that as an RN it is my duty to document whatever forms are needed. REALLY, SMH!! From what I have learned in the last 4 months is that RN Case Managers are in charge of going out to the patients house and doing the re-certification for medicaid services. What do you think I should do? Should I fill-out the form or not? What can I tell the non-nurse recruiter to get him off my back already?! PLEASE HELP!!

JustBeachyNurse, LPN

1 Article; 13,952 Posts

Specializes in Complex pedi to LTC/SA & now a manager. Has 13 years experience.

Sounds more like private duty. In my agencies (east coast) ANY RN can do a supervisory visit and a 60-day recertification however the nurses are scheduled/notified in advance. Using a charted by exception to essentially backdate a recert wouldn't fly. I think you are right in this case. If it were a few days later with a relatively fresh recall, not such a big deal. But weeks later when you don't have an accurate recall of the visit you would be making up data.

You may be obligated to do supervisory and recertification but not weeks post visit sans data and no recall


38,333 Posts

My RN primary nurse on a previous case did the recerts on our client but the agency put this requirement on her before the fact. Since there was a special problem (distance), it made sense. I take issue with the statement that your employer made that it is your responsibility as an RN. Of course you are in a better position to do this paperwork than someone who has never seen the patient, but as you correctly observe, you are not employed in the capacity. If they want you to do recerts, then they should change your job. Going forward. JMO


38,333 Posts

BTW, have worked for agencies that require their nurses on cases, including the LPN/LVNs, to "write" input for the recert narrative. We all saw what that was about. All the RN clinical supervisor had to do was to appear and look at the patient at recert time. Makes for quick uncomplicated recert visits.


10,301 Posts

Specializes in NICU, PICU, Transport, L&D, Hospice. Has 44 years experience.
he said that as an RN it is my duty to document whatever forms are needed


some forms should never be completed by a nurse.

any forms that the nurse should complete must be provided by the agency and to the nurse before or at time of the visit.

In my view you were right to refuse.

Good luck.

Specializes in Cardio-Pulmonary; Med-Surg; Private Duty. Has 5 years experience.

I'm the primary nurse for my agency for one PDN patient, and I did this month's supervisory visit in combination with my regularly scheduled shift.

No way in heck would I have filled out that paperwork three weeks after I laid eyes on the patient, nor would it be my responsibility to do so. Filling out that paperwork when you didn't actually do the assessment at that time would be fraudulent documentation, and you could lose your license for it.


2 Posts

Has 1 years experience.

Thank you guys so much for the feedback. I knew that it wasn't right, but hearing it from other experienced nurses makes me feel much more confident and not alone. Again, thanks!!