Dear Cassandra,
Why is American Home Health so hung up on little things like clinical notes? Almost every week someone from the office contacts me about my clinical notes. I go to work and take care of my client. Sometimes I don’t have time to write the nursing notes. Sometimes the supervisor says she can’t read them. Once I spilled coffee on the clinical notes. Once the client’s dog ate them. What am I supposed to do?
Perplexed in Palos Hills
Dear Perplexed:
What are you supposed to do? What kind of question is that? You know that you are supposed to write clear, legible nursing notes every two hours. You know the times and dates on the nursing notes have to match the times and dates you Clock In/Clock Out. You know that the nurse working the last shift of the week is to mail the nursing notes to the office. You know one week’s worth of notes is to remain in the home for reference.
Frankly, I’m surprised you haven’t been fired by now. Your excuses sound like the excuses of a high school student. The dog ate the nursing notes. Please! Every teacher has heard that excuse. So you spilled coffee on the notes. Well, rewrite them. So you have poor handwriting. Well, print.
Maybe you think good handwriting is not important. A man recently tried to rob a bank. His handwriting was so poor that the teller could not read the note. She asked him to write the note over again. Instead, he fled. The teller, of course, had activated the silent alarm. The robber was arrested by police waiting outside the bank.
Why is it critical to send the notes to the office in a timely manner? In some cases, American Home Health cannot bill for services without a copy of the clinical notes to accompany the invoice. In addition, in the event of an audit by the Department of Specialized Care for Children (DSCC) or the Illinois Department of Public Health (IDPH), the auditors review the clinical notes to determine the quality of care. The auditors also compare the times recorded on the notes to time billed. Discrepancies can mean paybacks to the funding body. If nursing care is not documented, it is as if it did not happen. That brings questions of possible fraud. Do you want to be accused of fraud? If, God forbid, a child should die under unusual circumstances, the nursing notes would be reviewed by the authorities.
Always proofread your clinical notes. If you work for multiple clients, check to be sure you wrote the correct client’s name on the clinical notes. Did you sign and date the notes? Did you sign the notes using the name which appears on your license even if you have a different legal name?
Do your clinical notes contain medical bloopers? Below are actual statements found in clinical notes of other medical providers:
“Patient was unresponsive and in no distress.”
“Patient is non-verbal, non-communicative, and offers no complaints.”
“Patient was apprehended and guarded.”
Do your notes contain a malapropism? That is an unintentionally humorous misuse or distortion of a word or phrase especially the use of a word sounding somewhat like the one intended. Did you write, “We had to use the fire distinguisher.” Did you say, “The client had an expensive pendulum around his neck, and it got caught in the Hoyer lift.”
What else can you do to correct the situation? Get a Palmer method handwriting manual and start practicing to improve your handwriting. Talk with your supervisor about time management skills. Keep liquids away from the clinical notes. Keep the notes in a safe place so dogs and children can’t get them. If you are responsible for sending in the notes, be sure you send the whole weeks worth of notes and that no pages are missing. Don’t wait until the end of your shift to document the events of the entire shift. Above all, change your attitude about the importance of clinical notes. Your job depends on it.
—Cassandra
Note: First published on American Home Health's news, January 2012.