niscie 0 Report Share Posted January 7, 2006 Hi, I have a question about charting... I have always done all of the charting { in the medical charts} in my past jobs, at my new jobs the assistants hve done some of it, which is fine by me!! but my question is do they have to be certified as a AA to do so? or does it not matter. I thought you had to be but they say you do not. Please let me know if you know the answer thanks!!! niscie :-D Quote Link to comment Share on other sites More sharing options...
Pennie 26 Report Share Posted January 7, 2006 Hi.. If you are in LTC / State funded, and you are the attending Certified AD, you are responsible for every word in the chart, if someone erases or scratches something out to re-do it.. you could lose your certification.. Assisted Living / private pay.. may be different, you would need to check with your state regs, and corporate policy.. Anyone with some additional info ..Please join in here.. this could get out of hand thanks, Pennie Quote Link to comment Share on other sites More sharing options...
niscie 0 Author Report Share Posted January 7, 2006 Pennie, I do work in LTC/ State funded. I didn't even thing about losing my certification :-o !!! I work in Ohio if that helps also. I will be talking with my Administrator on Tuesday. Any other info will be greatly helpful!!!! Quote Link to comment Share on other sites More sharing options...
Pennie 26 Report Share Posted January 7, 2006 hi.. you can let the assistants chart for you if you want .. not recommended but it can work if you sign off on everything.. The medical chart in LTC/State Funded is god.. if ever there is a lawsuit, a state inquiry.. they use the medical chart as basis for any discrepencies, imagine what a lawyer would do with something erased and changed in a medical record.. it would be an "OJ's Glove" all over again. Check with the DON .. she will enlighten you as to the regulations in your state.. Quote Link to comment Share on other sites More sharing options...
Guest Rhonda Holthe Report Share Posted January 8, 2006 Hello to all, just wanted to respond. I work in Oregon in a LTC/state funded facility. When I was an AA I could not chart in the residents charts. The AD did all that. I did chart in the participation records and the 1-1's. The AD would come and ask me questions before she would do the care plans or the MDS but I was not aloud to chart in the Charts. Now that I am the AD I do it all since I have no assistance. But if I did I dont think I would take the chance and have a AA chart. And here in Oregon I dont think that I could let them anyway. I think Pennie is right talk to your DON. Quote Link to comment Share on other sites More sharing options...
hcornell 0 Report Share Posted January 9, 2006 Hello, I happen to have a differing opinion on the charting matter. I work in LTC, and I am certified; however I feel, based on the current regulations , that as long as you have included this responsibility as part of the AA job description, then they are perfectly qualified to do the charting. (You would not have hired them otherwise). Of course as a department head, you are ultimately responsible for anything related to your department, so train them in your approved ways, and you should not have to worry. Best Regards, Heide Quote Link to comment Share on other sites More sharing options...
niscie 0 Author Report Share Posted January 10, 2006 Thanks everyone!! I am going to talk to both the adim. and DON tomorrow, I was off today, and I also sent a e-mail out to a ACC with the same ??? jsut waitting for a reply. Thanks again!! Niscie :-) Quote Link to comment Share on other sites More sharing options...
Pennie 26 Report Share Posted January 10, 2006 Just to clarify a few points: 1. You may never, never, erase, use white out, or scratch out anything on the medical chart. If a mistake is made you mark thru the mistake one line only, write error above it & initial it. 2. Anyone that is not certified as AD, ADC or TR can not sign off on any records in the chart. You're AA may write the progress notes, annuals, interviews sign them but the certified staff has to write "Reviewed, date it and sign off." 3. So since you have to review the records it may be just as fast to do it yourself. 4. YOU ARE RESPONSIBLE FOR ALL THE DOCUMENTATION ON THE CHARTS, IT IS YOU'RE LICENSE AT STAKE :idea: :-o 5. Me personally, I never allow anyone to do my charting. See the posting by Rhonda Holthe, this is same thing my ass't do. Quote Link to comment Share on other sites More sharing options...
niscie 0 Author Report Share Posted January 16, 2006 thanks for all the advice and I talked with my adim., DON, and I will be doing all the charting, which is fine with me... and my assisntants are happy too!! lol Quote Link to comment Share on other sites More sharing options...
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