after 25 years you would think it would get better

[Luci2Lu2]

I have been nurse for 25 years. It is part of my job to review a chart for regulatory compliance. There are times no matter how I present it a seasoned clinician will become very upset. Chart review is such a good thing because the review catches problems we can often correct before a surveyor does.

[tkhayman]

HI,

I agree with you. I had to do chart review once a week at a previous job and would also spot my own mistakes and it actually made me better at charting. But some people do get defensive.

[Jo Dirt]

I've never had a problem with being corrected, if it isn't done in a condescending way. I've had people who are nice about it and actually care about making things better and I've seen people use their information to build themselves up while making me look stupid.

But I also know what you mean because I know plenty of people who can do no wrong and for whatever reason can't take criticism. I've also noticed these are the ones who dish out the criticism quite liberally.

[ASSEDO]

I do chart review. What is a suprise is that - unless you perform an audit, you may not see errors on a medical record.

Example this week on a post review: A patient was on IV's and new TPN did not have a correct weight on admit (a conflict by 30 lbs). She did not have a repeat weight for over 30 days. The order was not written for daily weight. If you were a nurse, would you be concerned? If you were an insurance company, would you pay for this type of care?

Most hospitals must document according to Medciare/Medicaid regulation and other primary insurance requirements. If the documentation is not on the medical record, the hospital can be audited, fined, or closed down. Insurance companies can refuse to pay. Why the concern about insurance companies? They research the standard of care and issue regulation. If the standard of care is not given, the insurance company can deny a claim. InterQual criteria is an excellent example of this. Not documenting just one injectable, or the SAT rate can cause a inpatient denial, the hospital loses money and someone may lose a job. Its like the domino effect. The Code of Federal Regulation also gives regs on correct documented.