Wednesday, May 23, 2007

Who Cares About Documentation

Who Cares About Documentation? Nurses had better care and take action. Documentation is required as part of the nursing process. Documentation is not just some tedious task that can wait till the end of the day. A lack of documentation or inadequate documentation lends creditability to the premise that the nursing care was not provided. Inadequate documentation is a violation of the Board's rules and regulations and it can seriously harm a nurse in lawsuits as well. I hear over and over from clients that they wished they had documented "such and such" and "If only I had documented, I would not be before the Board." Nurses must change their way of thinking and organize their workdays so that they can timely and adequately document.


Tired Nurse said...

Got a letter for a complaint and investigation of my license.
While working at a home health agency, I used a pc program and electronic signatures for all assessments, drs orders, notes,etc. Many times the Administrator or the Clinical Director or the BOM or the Corporate reviewer would open my notes so they, or myself, could make changes. Some notes were re-signed by me and some were signed by them. Sometimes I had no clue when a note had been opened after I signed it unless I opened by files. Some were closed when I didn't know it. There are no hand written notes and I don't have a clue what patients they are talking about. I left employement there July 3 and turned in the computer and bag they issued me.
The agency is claiming I submitted nursing documentation on 2 patients for home visits that were in the hospital sometime in June to July 2. There were lots of notes and assessments incomplete and unsigned electronically.

This is Medicare Fraud they are claiming.
I have been a nurse for 20 years almost and have had one previous investigation that was cleared and case closed without my presence in Austin. What is the worst case scenario here? I just renewed my license. I'm not scared to lose the license, I had planned to leave nursing in 2009 anyway. But I am scared to go to jail. Who in Amarillo area would be an experienced attorney for me to retain,please?

Anonymous said...

Electronic entries can be traced and documentation timing can be authenticated. Our company uses a web based program and all entries into medical records have the documenter's name and time of entry, electronically 'stamped'onto the record in real time.

Taralynn Mackay said...

You don't need a criminal attorney yet because you don't know if the previous employers are turning you in for fraud. Ask around Amarillo and check references for a criminal attorney so that if there is a criminal investigation, you are prepared with the name of an attorney that will take your case.