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Does Auditing Feel Like a Losing Battle?

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Over the last 10 years I have spent a lot of time personally auditing records and collaborating with those who perform that task in homehealth agencies. No matter the size or location of the agency, there is a clear, common theme – the ongoing struggle to get clinicians to document skilled care.

Educational efforts take the form of in person sessions,webinars, books, articles and audio conferences yet the issues seen in content generated by nurses and therapists remain virtually unchanged.

  • 1) Incomplete assessments
    • a.Limited to no subjective input from the patient and caregiver
    • b.Objective information recorded but no clinical analysis
    • c.OASIS information inconsistent with narrative findings
  • 2) Goals that are long on number and short on focus
    • a.Goals that are actually tasks for the clinician
    • b.Lack of connectivity between the assessment, plan and goals
    • c.Measurement present but no clear meaningfulness to the patient
  • 3) Visits not showing “skilled need”
    • a.Repetitive visit note content
    • b.Inconsistencies between disciplines
    • c.Unclear relationship between visit notes and the plan of care

Let’s be honest – clinicians HATE to document . There is no quick fix for years of learned behavior from clinicians that repeatedly asks others “just tell me what you want me to write”. The time has come to address the core issue – do we understand “skill”.

Think about it this way - is a nurse still a nurse when she is shopping for groceries? Is a therapist still a therapist when he is riding a roller coaster with his kids? Does there have to be a ill or injured person within a certain number of feet for a nurse or therapist to step up and be his or her discipline? The answers are CRITICAL to the understanding of skilled care. Skill is in the sole possession of the clinician. He or she worked HARD to become proficient and that knowledge cannot be taken from them and is NOTdependent on an identified issue with of another person.

Skill is the contribution the clinician makes to a specific patient situation that is based on what they know that other people do not.  When we can master that point, documentation becomes the opportunity to show off those skills and not just a list of problems a patient has and tasks done. Skill drives how we CHOOSE those intentional interventions and WHY we chose those for this specific patient.

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