Who's charting is it anyway?

[Cattitude]

:chair: this is me hiding from my boss. she is always trying to make me rewrite what i have charted. let me state that i am not a new nurse and i have been in homecare for almost 4 yrs. she is very type a and gets on everyone's case, not just mine but this is really bugging me. she gets upset when i tell her that it's my name going on the document, not hers but i don't know what else to tell her. when she is trying to convince me to write it "her" way she says "it doesn't matter, it just sounds better". but then why does it have to be the way she wants it? she is so fearful of litigation for some reason (no we have never been sued) that it is really quite overwhelming. on one hand, i appreciate her expertise, on the other, i feel respobsible for what is charted and i don't always agree with her. any advice? thanks.

beez

[Daytonite, BSN, RN]

since i started studying health information management i have been learning a great deal about medical records and medicare reimbursement. your boss may just not be articulating effectively all the reasons why your charting is so important. practicing nurses are taught from school that their charting is to document what they see and do with the patient. in essence, that is what documentation should be. however, bosses are also getting pestered by the management people above them about budget and financial matters all the time. a good many home health services are paid for by third party payers (insurance companies, medicare and sometimes medicaid). what most nurses don't know is that these payers insist on documentation being present to prove that certain conditions exist and are being treated before they will hand over any money to your agency. having been a staff nurse for many years i know that most nurses don't like the sound of this, but keep in mind that we do owe our employers some loyalty and that includes doing whatever we can to help the business stay afloat. if that means documenting a little differently so that certain specific information gets into our charting so the services get paid then that's just what we have to do. the business staying open and us keeping our jobs kind of depends on this. what i have also been learning about huge entities like medicare is that they are pretty much leading all the other insurance companies around, so what they say goes. what many do not understand is that healthcare providers can get into huge heaps of trouble (going to prison kind of trouble + big fines) if services provided are falsified in documentation and are billed for. as nurses, we didn't hear about this in nursing school, but i guarantee you, it does happen. the government, in particular, wants to justify and know what every penny they are paying out is being spent for. i used to think the irs was scary, but they are nothing compared to what medicare can and will do to people who are trying to pull the wool over their eyes. on the other hand, each business wants to assure that they are going to get the maximum amount of money for the services they provide to their patients from these third party payers. consultants estimate that healthcare providers are losing millions and millions of dollars they could be legally collecting from third party payers because of failure to bill for services due to deficient charting or bad coding and billing. so, bosses want you to chart everything so a sharp biller can legitimately bill for everything they possibly can from a chart. when i worked as a coder, i was shocked at how many insurance companies and medicare just summarily declined payment of many services--period, end of story. it doesn't seem fair and has made it hard for healthcare providers to stay in business. one of the largest medical insurance providers would summarily not pay for the x-rays that were taken to confirm someone's broken bones that were subsequently treated. this kind of money adds up to millions of dollars over time. and, the healthcare providers can do nothing but refile a claim and hope it gets paid.

[DutchgirlRN, ASN, RN]

if a person is independent with ambulation, stairs, etc, then the admission should have been stopped if Medicare was the pay source realizing the homebound issue was not met

I respectfully don't agree with you. I've admitted many patients who were ambulatory including stairs and felt their admission was 100% justified. Patients such as these are usually discharged after a couple of weeks. I have worked for an agency that held onto them 60 days and recerted one or more times. That is wrong and I did refuse to do those visits. I've had coders/DON's insist that the patient be considered incontinent, etc...On the flip side I've admitted private insurance patients who desperately needed HH and couldn't get more than 2-3 visits approved for them. There are things wrong with the HH system but by in large HH works well and is valuable service when appropriate.

[NRSKarenRN, BSN, RN]

Patients CAN be independent with stairs and ambulation and still be homebound.

a. Post hospitalization for surgery when restricted to the home

b. Fraility: needs assistance family member to leave home

c. Newly diagnosed IDDM with blood dugar fluctuations: unsafe to

drive till stabilized.

d. Alzheimers/Dementia patients: need 24 supervision.

These are things can think of off top my head.

Now if they are going to store to pick up meds then drive for haircut or dinner with buddies/lunch with ladies, nope not homebound.

[DutchgirlRN, ASN, RN]

Thank you Karen. I was in a sleepy stupor this morning and couldn't come up with any examples.

[runrn]

I used to work for an agency that had "team conferences" that consisted of asking every person involved with patients care to give their opinion on the oasis questions. It was a joke...most times the answers were never the same and it would end with the supervisor choosing the answer that would yield the most points on oasis score. When the time came for the R.N. to do the recert, the results of the team conference were given to you as though it were your guiding light. If your answers didn't jive with the ones given to you, then you would get hell. I certainly have nothing against getting input from nursing assistants who know these patients the best, but as far as oasis questions go, I only resort to doing this if I feel the patient isn't being forthcoming, or if I felt I didn't get my point over well enough to get an accurate answer, and if I'm teeter-tottering over two choices. But it has to be my choice, I have to know the assistant well and trust her opinion. I once read somewhere (maybe on here) that the oasis is not a "group effort". I liked it so much I used it one day at work when they irritated me to the point of wanting to hurl my chair at them. They didn't like it, but it beats the heck out of an armrest upside the head. (Kidding, really)

[runrn]

It beats the heck out of me that nurses would risk their entire career by encouraging fraud within the medicare system. And for what? Most of these nurses are on a typical salary with no special perks. How is it that they take that kind of risk at a time when whistle-blower lawsuits are at an all time high? I think there should be mandatory education on fraud before a nurse enters the home health arena with major point being: If you get convicted of medicare fraud, even if you don't lose your license, you get excluded from the entire program itself. Which means you can't get a job working anywhere that medicare is a payor source. Correct me if I'm wrong here.

[caliotter3]

runrn

You need to look at some of the people I used to work with and tell them what you said in this post. I totally agree with you. Sometimes a person has to just burst at the seams keeping their mouth shut or straining to look in the other direction. I have symptoms just from trying to figure out how things are supposed to be. Ducking and dodging other people's behavior is added stress and encountering head in the sand supervisors is a pain. It would be so nice just to be able to go to work and take care of patients the way they're supposed to be taken care of instead of spending a good portion of one's time trying to stay away from somebody else's fraudulent acts.