Avoid a tangled web of untruths in your nursing documentation

A reader submitted a question about nurse managers in a home health agency documenting the start and stop times for IV infusions. The nurse managers did not administer the IVs. The reason this practice occurred was so the nurse managers could be paid for the infusions.

A long-standing, essential principle of nursing documentation is that it be truthful and accurate. Moreover, you as a nurse are responsible for your own documentation.

If you document for another, you must alert the reader of that fact by indicating you are doing so for the identified nurse (by name) and then signing your name after the notation.

If these legal and ethical standards are not met, the documentation that takes place is considered false, untrue, misleading and deceitful.

False, untrue and deceitful documentation results in grave safety issues for a patient. Because the nursing team depends on what others have documented in a patient record, when those entries are false, the patient may suffer a double dose of a medication, a medication may not be given at all or a patient’s condition is treated incorrectly, as examples.

False, untrue, and deceitful nursing documentation also can result in health insurance payments when not warranted.

Several ways this practice is troublesome

In the reader’s question, several legal issues arise. First, the nurse managers are documenting something they did not do. This is their first legal blunder.

Second, it is assumed a nurse manager in this home health agency does not visit daily. Rather, he or she visits in order to oversee those who are providing care and also to assess the patients’ conditions and improvement as required by insurance carriers, the state home healthcare act, the state nurse practice act and other applicable laws and regulations.

If that is the case, the documentation done by the nurse manager is not “timely”. In other words, although the start and stop dates may be accurate, because whomever initiated the IV and stopped it informs the nurse manager of the accurate times, the documentation is not contemporaneous with the dates those actions took place.

How much of a delay occurs due to this practice is one concern. The other is how the nurse manager is indicating the start and stop dates in the record. Are the entries backdated? In other words, if an IV was stopped on Wednesday, January 12, is the entry dated as such even though the documentation took place on the 16th, or is it entered on the day the nurse manager actually documents the stop date, indicating it as a “late entry” or as an “addition to the notation” pursuant to the agency’s documentation policies?

Another instance of legal inaccuracy is if the nurse manager backdates the notation. If, on the other hand, the nurse manager dates the start and stop dates truthfully but indicates the actual date of the entry as well, that is legally acceptable.

It may not be acceptable, however, for the insurance company who is paying for those IVs, whether its Medicare, Medicaid or a private insurance company.

As a result, not only is the nurse manager falsifying the record, the practice may result in a non-payment by the insurance company for the IV because it was not timely documented.

Another legal question is who exactly is starting and stopping the administered IVs? Are they RNs? If so, what would prohibit them from documenting the start and stop dates in the record themselves? Or is IV initiation and termination not within the scope of the home health staff member who is doing so?

If the staff member’s scope of practice does not include working with IVs, this practice would clearly compromise the staff member’s license and/or certification, leading to a potential for a professional discipline by the state agency that licenses and/or certifies the staff member.

Likewise, the nurse managers who are engaging in the false nursing documentation face a professional disciplinary action by the state board of nursing. Falsification of nursing documentation; unprofessional conduct likely to deceive, defraud or harm the public; and not meeting standards of nursing practice are examples of grounds upon which the board could allege against the nurse managers.

And the home health agency itself could face losing its license as a home health agency due to its support of this particular practice.

One last legal problem raised by the reader’s question is that the nurse managers were falsely documenting so they could be paid for the infusion. Does this statement mean the nurse managers personally were being paid as a result of their visit and documentation? Or does it mean the agency was being paid for the visit? Unclear, to be sure, but still troubling.

It is important that as a nurse licensee you never falsify nursing documentation or any document in relation to your nursing practice. Your inability to practice nursing with an unencumbered license is but one ramification if you do so. Another consequence is that your veracity will be severely compromised, a result that will follow you for the rest of your professional life.

Take these courses related to fraud and documentation:

CE158-60: Healthcare Fraud
(1 contact hr)

Healthcare fraud continues to drain billions of dollars from the U.S. healthcare system annually and depletes the system of valuable and limited resources. Healthcare professionals, as patient advocates, are in a unique position to support patients in obtaining and keeping the healthcare services they need by helping to combat fraud. Nearly every healthcare service type has been involved, or has the potential to be involved, in fraudulent activity that healthcare professionals can help eliminate. Often, they have access to information that enables them to identify fraud long before investigators or law enforcement officers do. As advocates, healthcare professionals can help patients to recognize and report fraud, and help employers avoid fraud.

CE548: Protect Yourself
(1 contact hr)

Nurses have an obligation to keep abreast of current issues surrounding the regulation of the practice of nursing, not only in their respective states, but also across the nation, especially when their nursing practice crosses state borders. Because the practice of nursing is a right granted …read more

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