In an age of electronic records and an economic recession, the nurse must be diligent about thoroughly assessing the client using a head-to-toe format and charting all findings in detail. Medicaid/Medicare has really tightened their laws on what they will and will not reimburse. For example, if a patient is admitted to the hospital and the nurse fails to chart that the client had an already present pressure ulcer, Medicare will refuse to reimburse the hospital for fees, supplies, and procedures related to the treatment of that wound. However, if the pressure ulcer is charted as being present upon arrival, the hospital is not at fault and will be reimbursed fully. Another example, separate from charting, is when a patient is discharged from the hospital following a heart failure “tune-up” and is readmitted within 30 days. The hospital in penalized for the re-admission. The problem is that there are other factors that could cause the re-admission that is not the fault of the hospital or physicians. What if the patient is non-compliant with the prescribed medication regiment? Should the hospital be a fault? Also, we care for a high risk, end stage heart failure population, so is it fair that our stats must match up to a rural hospital that only cares for mild cases of heart failure and does not perform transplants?
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