Tag / computer documentation

by Julianne Haydel

Predictive Analytics


I just saw an advertisement for a company offering predictive analytics so that within minutes after the clinician inputs data, predictions are made. It even tells you how many visits will result in a good outcome and what kind of visits those are. There’s another tech company that guides you to better allocate your resources (you are the resource, by the way).

Although I love computers, I wonder if we are trying too hard to substitute computer data for critical thinking. Using computer predictions to determine how much care should be delivered has too many opportunities to fail, and failure in nursing harms patients.

The algorithms in this and other programs are based on thousands of patient episodes. In theory this is good. Validation is achieved by the repetition of results across many occurences. TUG tests and PHQ depression assessments are validated but those results are not influenced to any great degree by data that we are unable to measure.

So, agency owners who are interested in these data crunching, predictive programs might want to ask what information goes into making these predictions and what variables can influence the data. OASIS and basic assessment data is readily available but OASIS does not ask about income or education level; both of which influence a patient’s response to care provided. Typical assessment data does not provide insight into family dynamics or how far it is to the nearest grocery store, hospital or their MD office.

If nurses surrender their own critical thinking to these programs, they are primed to violate the most fundamental of nursing standards by not individualizing care for the patient. Only the assessing clinician can do that. If non-clinical managers use these programs to determine the value of a nurse, he or she may end up on the radar simply for providing the patient what is needed.

I have never seen a computer program brought before the board of nursing or any of the therapy boards. If the computer advised the nurse to insert a knife into the eye of the patient, the computer would not be held accountable for the resulting loss of vision. The nurse is and always will be ultimately responsible for the nursing care rendered to the patient.

The legal implications are enough to make me glad I am not a lawyer and cannot give legal advice. That’s not to say you won’t wish you had called a lawyer before you allowed a computer to make clinical decisions for you.

I am an information junkie. If I had access to one of these programs, I would play with it the way Sheldon and Leonard played Halo on Wednesday nights. But I don’t think that is how this predictive technology will be used. My fear is that clinicians will be judged on how many visits they provide and whether the number falls within the computer generated parameters. I am afraid that careplans will be altered to accommodate an algorithm, and the patient will receive care they do not need or not receive care they do need.

There are no recipes for patient care – add five visits and a teaching guide for diabetes; stir well and season to taste with footcare. The best software helps clinicians care for patients. A good system frees up time by handling non-clinical tasks and minimizes the work of complete and accurate documentation . (No routine visit nursing note should require 20+ pages when printed.) Documentation in the home during a visit is ideal but not if it puts the computer between the patient and the clinician. Making information available when needed is much different than a Where’s Waldo game to locate vital signs in a sea of useless information.

Most State Boards of Nursing have a statement similar to the below taken from the Louisiana State Practice Act:

The standards are based on the premise that the registered nurse is responsible for and accountable to the individual for the quality of nursing care he or she receives. Documentation must reflect the quality of care.

If you are unable to find a similar statement in your state’s practice act, look for one that says:

Computer directed nursing is acceptable should the nurse not feel up to thinking critically.

You probably won’t find anything like that. Registered Nurses are able to delegate tasks but never responsibility.

If you have a different opinion, we’d like to hear it. Please email or leave a comment. And remember, we are information junkies and do not want to go into flagrant withdrawals but we also think you can do a better job of caring for patients than any software, anywhere, anytime.

And we can help. We have coding and OASIS certified nurses ready to review your admissions and give you the information you need to craft a care plan.

by Julianne Haydel

Computer Charting


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Computers are tools.  They give your staff the ability to surf the net, check FaceBook or even work.  Sometimes, surfing the net would be preferable to the computer documentation I have had to suffer through lately.

This is not a new pet peeve but it is regularly exacerbated.  One idea is to turn off the software’s ability to carry over visit note content from one day to the next.  Agencies are afraid their nurses would quit if they did that.

Just two weeks ago, I wrote a plan of correction for an agency that addressed essentially duplicate notes.  It seems the surveyors are also noticing very little original content in visit notes.  The plan my client decided on was to disable the ability to cut and paste for one week for an initial offense for a nurse, a month for the second and permanently for the third.  This only works if you system allows you to individualize each user’s abilities.

Everyone uses templates and revises old documents and contracts to make new ones.  Everyone’s phone rings and has distractions.  The difference with clinical documentation is that typo’s are the stuff of Medicare Fraud and Abuse.

Do you know Daniel R. Levinson?   He holds the position of Inspector General of the United States.  When someone refers to the OIG, they are referring to his office.  Unless you are paid handsomely to defend someone against charges brought by the OIG or you play tennis with him, you never want to hear your name in the same sentence as Daniel Levinson’s.  So, having said all that about the Inspector General, let’s hear what he has to say about your computer documentation.

Experts in health information technology caution that EHR technology can make it easier to commit fraud. Certain EHR documentation features, if poorly designed or used inappropriately, can result in poor data quality or fraud.

This next one kind of gets under my skin a little but he is absolutely correct.  I just wish he would remember that the most important reason to document is to improve patient care by committing to writing pertinent facts about the patient and their treatment.

When doctors, nurses, or other clinicians copy-paste information but fail
to update it or ensure accuracy, inaccurate information may enter the
patient’s medical record and inappropriate charges may be billed to
patients and third-party health care payers.

The Inspector General highly recommends the use of audit tools, as well.  I’m not sure that is an effective solution to all but the most egregious offenses.  The nurses I know sign their name to duplicative documentation.  I know nurses who share passwords all the time.

The only time that I have ever detected the appearance of actual fraud is when nurses documented more visits than are possible on a single day with over lapping times.    I know from frequent experience that it is easy misdate a handwritten signature or document.  Computers are far more reliable than most humans in getting the date straight.

The best audit tool begins at the hiring process.  People with integrity do not commit fraud.  We have all been desperate for someone to fill an urgent need in the schedule and plugged in the wrong person who had not been vetted properly.   That’s a painful mistake because ultimately, the agency is responsible for what happens inside its organization.

The second best audit tools are the back office people and coders who read scores of documentation.  They will notice duplication and unlikely events sooner than a QA nurse who is reviewing a smaller percentage of clinical records.  Coders and billers spend hours of time at computers each day.  They make scores of errors, correct them and move on to the next plan of care.  When they see an obvious typo, they don’t see it as Medicare fraud because, get this –nobody is actually trying to commit fraud.

The only people who view these typos and occasional duplicated notes as fraud are the ones who can deny you payment or arrest you.  If I were you, I might take a second look at your computer documentation practices.

Just saying….