How should healthcare providers cope with unsigned time sheets by a currently dismissed worker?

Question:

Dear Nancy,

I’m the nurse manager within the operating room at an ambulatory surgery center. RN was recently launched from the middle? and rightly so? by our administrator who shouldn’t be an RN or clinical skilled. She asked me what to do with the unsigned nursing notes of a fired RN. The lack of RN documentation and unsigned nursing notes are only the tip of the iceberg and I do not think it could be clever to call him back after his release to sign his notes. Can we sign as “exempt employee”? signature on the file? In this case? How should health care providers handle unsigned or uncertified time sheets prepared by a currently terminated worker?

Lucyna

Nancy Brent replies:

Dear Lucinda,

Suffice it to say that within the situation described in your query, there may be little that could be done to correct problems in a terminated worker’s medical records. Although the issues are serious, the solution to cope with these kinds of situations is to implement a facility policy and procedure that often monitors patient admissions for care and requires providers who’ve deficiencies of their documentation to correct identified problems. Many such policies and procedures also involve disciplining a healthcare provider who ignores any requests to finish documentation in a timely manner.

Corrections, additions to an entry, authentication of an entry or late entries, for instance, must be treated in accordance with the institution’s policy. For example, a late entry should be identified as such when entering the present date and time. The addition to the entry must also reflect the present date and time, can or not it’s marked as an “addition”? and this must be done as soon as possible after the unique entry has been accomplished.

Before you do anything with chart data, you and your administrator should discuss the matter with the chance management department and the power’s attorney. While there may be little that could be done on this particular situation, it might prompt the power to adopt a policy requiring regular monitoring of patient records or strengthening existing ones.

A facility that fails to require timely and complete documentation and fails to often monitor records during a patient’s stay may face serious sanctions if an accrediting agency akin to the Joint Commission, a state licensing agency, or a visit by a federal Medicare/Medicaid inspector discovers incomplete records of care patient. Furthermore, a person health care provider who fails to fulfill his or her responsibility to document patient care in accordance with legal requirements and ethical skilled standards may face potential disciplinary motion from the state board that licenses that health care provider.

Heartily,
Nancy