Charting in several places can avert legal snafus
ICUs that rely on flow sheets are exposed to risks
A report issued last year by Milliman and Robertson health care consulting firm reveals that nearly 54% of all inpatient hospital days were medically unnecessary.
A great deal of the hospital care, according to the New York City-based consultant, could have been provided in an alternative setting such as a nursing home or a home care program.
In New York, for example, 72%, or nearly three-fourths of inpatient days in 1997 were deemed extraneous to good patient care.
Insurers and third-party payers are seizing such findings to justify closer scrutiny of hospital patient care trends, hospital utilization experts say. And while most of the attention focuses on general medical and surgical suites, critical care units are being put under the same microscope, says Gayle H. Sullivan, RN, JD, an attorney and former nurse who reviews hospital patient records for malpractice insurers.
It isn’t just cost effectiveness that is prompting the review of hospital care. Government payers such as Medicare and state regulatory agencies are investigating providers for alleged legal improprieties. In the past five years, the federal government has waged an extensive fraud and abuse initiative that has netted millions in alleged Medicare and Medicaid hospital overpayments.
In assessing a hospital’s resource utilization, the first place auditors are likely to look is a department’s patient documentation, Sullivan says. In most cases, the auditors will be looking for standards of care or omissions as reflected in the record.
In critical care, the growing use of flow sheets and other simplified forms of documenting a patient’s condition opens nurses up to substantial legal and professional questioning, says Sullivan. The questions arise when a lack of more extensive documentation isn’t available elsewhere, either in a computer file or the complete paper chart, Sullivan notes.
Collectively, flow sheets may yield a good picture of patient-care management trends over several days or weeks, but at best they reflect only a snapshot, says Sullivan. They can’t adequately explain, for example, why a patient’s intravenous insertion was left unchanged for three days or the reason a patient’s weaning from a ventilator was interrupted, then resumed during the third day.
Some nurse managers advise documenting in more than one place so that the entries supplement and reinforce each other. If nurses rely heavily on using flow sheets, other sections of the medical record should contain entries and supplemental notations that clearly reflect the content of the sheet, says Kathleen Rafferty, RN, MS, cardiology ICU patient care manager at St. Elizabeth’s Medical Center in Boston.
Nurse managers acknowledge that flow sheets are a handy tool because they simplify some aspects of charting and free nurses to spend more time on patient monitoring. Flow sheets are essentially a set of algorithms or checklist that reflects a patient’s care plan or outline a set of smaller nursing protocols such as prescribed nutrition levels, feeding times, or blood pressure assessments within specified time intervals.
However, using flow sheets tends to reduce the likelihood that nurses will spend sufficient additional time in writing thorough, detailed patient entries in the chart’s progress notes. The written notes are much more descriptive; and when written correctly, they contain well-supported observations on a patient’s condition at a particular point in time, says Carole Kenner, RN, DNS, a critical care nurse and professor of nursing at the University of Cincinnati in Ohio.
"A great deal depends on exactly how a hospital adopts these time-saving tools and how well nurses are taught to use them," Kenner says.
The Joint Commission on Accreditation of Healthcare Organizations in Oak Brook Terrace, IL, the American Hospital Association, and the American Medical Association, both in Chicago, have each promulgated proper documentation standards.
The American Health Information Management Association, also in Chicago, publishes charting and coding standards. (For information about these resources, see the box on right.) Your hospital’s medical library or risk management department should be able to furnish additional resources. For the ICU, here are some relevant considerations:
• Standardize documentation parameters.
In the ICU, the nurse documentation tracks the patient’s medical status in short-term intervals. Therefore, the documentation requires careful, regular maintenance, Rafferty says. In addition to highlighting key patient-assessment factors such as vital signs, pain level, and respiratory data, the flow sheet must be able to supplement and support other corroborative documentation such as medication orders or the full medical record, Rafferty says.
• Establish clear-cut procedures when relying on flow sheets.
If the unit adopts a flow sheet, it must be standardized to reflect consistency in daily bedside management, Kenner says. Deviating from the sheet or improvising even slightly between shifts defeats the purpose of a care plan, but it also makes keeping a complete record of care virtually impossible, Rafferty says.
• Design care maps to be as specific as possible.
Written care maps represent the third major source of documentation in the ICU, Rafferty observes. If consistently and completely filled out on each shift, the flow sheet can support the care maps and also the corresponding areas of the complete medical record.
• Assume the need to troubleshoot problems more often than in other departments.
Sullivan advises doing random chart audits internally (i.e., within the department) more often than the hospital’s standard policy. Regular monthly audits are appropriate. Prior to commencing, establish criteria or standards that will be met, says Sullivan. For example, establish goals for determining how often and how thoroughly nurses document patient vital signs during the night or weekend shift.
• Review the flow sheets weekly.
Weekly reviews will generate discussions on ways to improve how nurses view and utilize the sheet, Rafferty says. The nurse manager and nurse educator should meet with the bedside nurse during the review, which is conducted according to a checklist that corresponds to areas of the flow sheet. The checklist highlights areas of concern at St. Elizabeth’s, but it might vary depending on the patient’s DRG or changes in the nursing care plan.
Rafferty suggests all nurses bring the flow sheet into the patient room and use them directly at the bedside. "It cuts down on having to remember what to document later or duplicating your note-taking," she says.
Sources
For additional information about proper medical record documentation contact:
• Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 916-5636 Web site: www.jcaho.org.
• American Hospital Association, Coding Clinic, One N. Franklin Ave.,Chicago, IL 60606. Telephone: (312) 422-3000. Web site: www.aha.org.
• American Medical Association, Coding and Classification Section 515 N. State St., Chicago, IL 60610. Telephone: (312) 464-5000. Web site: www.ama-assn.org.
• American Health Information Management Association, 919 N. Michigan Ave., Suite 1400, Chicago, IL 60611-1683. Telephone: (312) 787-2672. Web site: www.ahima.org.
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