Staying Late to Chart: Is it Even LegalHealthcare Training Resource
February 17, 2014 — 1,371 views
Every medical hospital or clinic requires the assistance of nurses to handle both medical and administrative work. These nurses are required to update information given to them by the doctor in their internal portal for archiving purposes, as well as legal purposes. What happens on most days is that these nurses are swamped with work, that there is almost no time in their scheduled working hours to get the job done. However, they are required to stay at the hospital until that they have finished their computer documentation.
As of now nurses are expected to document the day's proceedings with regard to each individual patient every two to three hours. The system, which is purchased by the hospital, can be difficult to work with. This difficulty forces the nurses to stay back even after their shift timings to work overtime, or even use their personal time to complete their charting work. There is also a possibility that the nurses who are working on their own time could get into trouble in accordance with the Health and Insurance Portability and Accountability Act.
How to Rectify This Legally
The medical staff, if facing any problem with the functionality of the computer system, should speak to the IT department for assistance as well as the immediate supervisor. According to the standards that have been laid out by HIPAA, the documentation process should take place within an hour of administering a treatment or making an assessment. The problem with untimely documentation is that it can be used by the plaintiff's attorney as a non-credible documentation which could hurt the hospital in case of a lawsuit.
The current trend is that most nurses document their patients’ assessment after the initial round, which usually happens sometimes during the shift. As the patient's status changes during the day, the nurses update the status at the end of the day. It is best for the nurses to keep to their end-of-shift documentation brief so that there are not many changes in the patient's overall status.
Question of Overtime
In terms of overtime, the administration must be more consistent with its practices. In the case where a nurse is unable to finish his/her patient's care and documentation during regular shift hours, then it is appropriate for him/her to have overtime. In this case, it comes down to the competency of the immediate supervisor. By the time the nurses get used to the computer system, the supervisor should get a clear idea of which nurses are efficient at documenting and which ones are not. The ones that are not efficient should be given time at the end of their shift to finish the documenting procedure. If not, the administration should focus more on creating a more balanced schedule which is not hectic for the nurses, so that they can balance out their shift more easily and finish their documentation on time. Then there will not be any need to worry about overtime.