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Since I am not employed by the hospital, I believe it's the social worker's responsibility to change things such as discharge codes in a patient's record. Can you give me your opinion on this matter?

Wednesday November 6, 2013
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Question:

Dear Nancy,

I work as an RN external care manager for a sub-acute rehab facility, which is a partner company of a health system. I am not employed by the hospital, but my office is located there. We are about to go live with electronic health records, and it has brought about an issue. Since I expedite the discharge of patients from the hospital to rehab, the social work department is requiring us to go into the system after the patient is discharged and record all details, including changing discharge codes and signing off on the EHR to close out the record.

My stand is that a discharge belongs to the social worker. As I am not directly employed by the hospital, I have no right to change anything in the record or close it out, but instead these are tasks the social worker should do. Can you give me your opinion on this matter?

Stephanie



Dear Nancy responds:

Dear Stephanie:

The request from the social work department is a little strange, given that it is the social worker who discharges the patient, according to your comments. There should be some sort of policy about this situation from both the hospital and the sub-acute rehab facility and they should be identical as to which documentation is done by whom.

Even if there is no policy (you should start trying to get one in place for your role at least), basic principles of documentation apply here. First and foremost, no one documents for another healthcare colleague except in special circumstances (a scribe, a supervisor who may be documenting for a staff nurse who for some reason cannot do his or her own documentation). As you know, when one does document for another, it must be included in the documentation so the reader knows who did the notation (e.g., "Per Mary Smith, RN, the patient left the facility at 8:10 a.m. Jane Jones, RN").

Usually documentation for another occurs within the same profession (e.g., a nurse for a nurse). Clearly, you would not ask a social worker to document your responsibilities in this, or any other, process involving patients.

It is also important to note that you need to document what your role is and what you did for the patient to expedite the patient's discharge from the hospital to a rehab facility.

You might want to consult with your company's legal counsel to get guidance and clarification on this issue so everyone is on board and applies the same approach to a patient's discharge. It is assumed that both your company and the hospital would want a unified approach to which healthcare provider has responsibility for documenting the required information you have identified in your question.


Regards,
Nancy




Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.