I wholeheartedly agree that use of forms and documentation has gone over the top. We all literally cringe with the advent of a new policy with new forms but our experience with survey is "if it isn't documented it didn't happen" and we get cited despite best efforts. We seem to have a never ending battle to get quality charting about anything let alone regulation adherence proof and unless we want to micromanage by reading all notes and following up as needed we need forms. It is the only way we can ensure all bases are covered. The saddest part of all is that we are all so busy with paper either the resident suffers or the nurse suffers cause she is working 60 hours a week to "do it all". We tried to discuss the problems with excessive documentation/IDCPT meetings about everything under the sun with the state and they gave us a "you can do it" pep talk. What's that saying "ours is not to question why, just to do or die"?
-----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Holly McGran Sent: Thursday, November 13, 2003 9:03 AM To: [EMAIL PROTECTED] Subject: RE: self admin of medication FORMS are a direct result of an overregulated and scrutinized industry - longterm care/Nursing Home. Nursing homes have gotten to the point that they are so afraid they are going to miss something that the state is looking for they are trying to cross all t's and dot all i's with forms. I have been in the industry a long time and I disagree - we do need forms - Nurses can not possible document every component of a particular regulation (never mind interpretation of that regulation) off the top of their heads. And for those facilities using agencies - it is impossible. Read the regulations on Self-adm. of medications - the requirements are specific - miss one component of it in your documentation and you are wide open for a deficiency. When OBRA came along there was a period of time I saw a difference in surveys (in CT) - they were actually looking at residents and outcome. My experience now is we are back to documentation focused surveys. Forms serve a purpose. Holly QI in CT > -----Original Message----- > From: [EMAIL PROTECTED] [SMTP:[EMAIL PROTECTED] > Sent: Wednesday, November 12, 2003 10:46 PM > To: [EMAIL PROTECTED] > Subject: Re: self admin of medication > > Please do not use faxed forms that you copy and copy and copy and the result is a very sloppy record. > > Use clean, professional looking forms. Actually YOU DO NOT NEED A FORM. Briggs has [or will] fax you a sample. Use the sample and do a narrative note. I am of the opinion that the reason documentation is not adequate, complete or pertinent is because we are so locked into forms. If we do not have a form, we cannot document. > > Anyone see the kids movie "A Bugs Life." Remember when the leaf fell in front of the line of ants they did not know what to do? Well, that is what forms do to us, no form, we stop dead in our tracks and do--no documentation. > > A few months ago one of my clients had a nurse not admit a resident, that arrived before noon, because she could not find an admission packet. > > We need to get out of that way of thinking. > > Delores > > > > > Can someone send me via email a self admin of medications assessment, please? I do not have time for the briggs forms to be mailed and recieved, i am trying to accomplish the tasks of the assessments this afternoon. many thanks! > > > > > > Delores L. Galias, RN, RHIT > > STATEMENT OF CONFIDENTIALITY: > The information contained in this electronic message and any attachments to this message are intended for the exclusive use of the addressee(s) and may contain confidential or privileged information. If you are not the intended recipient, please notify D. Galias, RN, RHIT immediately at [EMAIL PROTECTED] and destroy all copies of this message and any attachments. Thank you for your cooperation > > /---------------------------------------------------------- The Case Mix Discussion Group is a free service of the American Association of Nurse Assessment Coordinators "Committed to the Assessment Professional" Be sure to visit the AANAC website. Accurate answers to your questions posted to NAC News and FAQs. For more info visit us at http://www.aanac.org -----------------------------------------------------------/ /---------------------------------------------------------- The Case Mix Discussion Group is a free service of the American Association of Nurse Assessment Coordinators "Committed to the Assessment Professional" Be sure to visit the AANAC website. Accurate answers to your questions posted to NAC News and FAQs. For more info visit us at http://www.aanac.org -----------------------------------------------------------/
