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Documentation: Our Best Defense for Scrutiny. Why focus on Documentation Competency? Communication of Resident Care –Among ISC clinicians, physicians,

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Presentation on theme: "Documentation: Our Best Defense for Scrutiny. Why focus on Documentation Competency? Communication of Resident Care –Among ISC clinicians, physicians,"— Presentation transcript:

1 Documentation: Our Best Defense for Scrutiny

2 Why focus on Documentation Competency? Communication of Resident Care –Among ISC clinicians, physicians, caregivers, other health care professionals Development of clinician skill set –Promotes quality resident care through assessment, reassessment, planning and development –Objective feedback provides opportunity for growth and training Justifies need for services –“ Paints the picture” of the medical and functional deficits of the patient –Documentation of skilled treatment necessary to return the resident/patient to their prior level of function

3 Why Focus on Documentation Competency? Proactive Approach to Increased scrutiny –Increased ADRs across the Country –RACs, ZPICs, OIG, State Surveyors Reduces Risk of: –Payment Denial –Legal dispute and clinical scrutiny Remember the old saying “If it isn’t documented... it didn’t happen”!

4 Objectives 1.Identify Top 5 areas of documentation focus 2.Provide training and support to improve 5 key areas of documentation 3.Implement documentation strategies to withstand scrutiny 4.Reduce rate of denial and ADR request volume 5.Improve survey / audit outcomes

5 Objectives 1.Identify Top 5 areas of documentation focus 2.Provide training and support to improve 5 key areas of documentation 3.Implement documentation strategies to withstand scrutiny 4.Reduce rate of denial and ADR request volume 5.Improve survey / audit outcomes

6 Objectives 1.Identify Top 5 areas of documentation focus 2.Provide training and support to improve 5 key areas of documentation 3.Implement documentation strategies to withstand scrutiny 4.Reduce rate of denial and ADR request volume 5.Improve survey / audit outcomes

7 Objectives 1.Identify Top 5 areas of documentation focus 2.Provide training and support to improve 5 key areas of documentation 3.Implement documentation strategies to withstand scrutiny 4.Reduce rate of denial and ADR request volume 5.Improve survey / audit outcomes

8 Objectives 1.Identify Top 5 areas of documentation focus 2.Provide training and support to improve 5 key areas of documentation 3.Implement documentation strategies to withstand scrutiny 4.Reduce rate of denial and ADR request volume 5.Improve survey / audit outcomes

9 Who/What influences Documentation Standards/Requirements? CMS – Center for Medicare and Medicaid Services –sets national guidelines Medicare Administrative Contracts (MACs) –a CMS contracted third party that sets local guidelines for payment –(Example: Wisconsin Physician Services) Regulatory Agencies –(Example: JCAHO, Rehab Agency, Home Health) State Practice Guidelines –(Example: TX HCSS, practice acts) Results of Probes, Reviews, and Audits performed by these agencies

10 Primary template for documentation set by CMS and the MACs –Define payment for services –Other regulatory agencies also provide direction,i.e., CoPs for RA, HH, Hospice –Ongoing change of requirements and standards ISC Model and Standards: –Our proactive model requires strict adherence to quality documentation to support and demonstrate medical necessity, functional deficits, skilled treatment Who/What influences Documentation Standards/Requirements?

11 Resources for Documentation Guidelines National Coverage Determinants (published by CMS) Local Coverage Determinants (published by Medicare Administrative Contractor-MAC) State Practice Acts (State Licensing Board) ISC chart audit forms (BSL net) ISC Personnel –Coordinator –Director of Therapy Services –Director of Professional Services –Regional Director of Operations –Regional Director of Appeals –Regional Director of Training –Senior Director of Operations

12 Essentials in Documentation Technical Completion/Accuracy Medical Necessity of Skilled Intervention

13 Technical Accuracy: Required Documentation Components All Documents (including orders) are... –Present Utilize Medical Record Checklist for Outpatient and HCC HCHB –Compliance with workflow – All supporting documents scanned into system –Timely and Dated Ensure EACH document / note has a date and is completed on the date of service Ensure EACH order is signed and dated by clinician or physician Follow regulatory requirements for timelines

14 Technical Accuracy: Required Documentation Components (continued) Complete: NO spaces left blank Indicate “not assessed” or strike through the item (paper documentation only) Organized (See Chart Set-up in Documentation Manual) Signature, Credentials and printed name (e.g. John Smith, PT John Smith, PT) Legibility Auditor should be able to clearly read documentation Avoid overcrowding the forms

15 Documentation Timeline Expectations RequirementHome HealthOutpatient/HCC Orders Verbal orders required prior to initiation of eval and/or any changes in POC Signed & dated MD orders required prior to initiation of eval & tx. and/or any significant changes to POC Evaluation/Assessment Perform w/in 48 hours of referral Perform w/in 48 hours from receipt of order Completion of Initial Evaluation Certification Form On Date Services ProvidedOn Date Services Provided (no later than 9:00 A.M. following day) OASIS Completion 4 calendar days from SOCN/A Physician Signed & Dated Evaluation Form Must have by End of Episode or prior to billing of claim Within 30 days from SOC; should f/u at 14-day assessment if not received to ensure compliance Daily Visit Notes Point of Service / By Daily Close

16 Top 5 Focus Areas for Medical Necessity Medical and Treatment Diagnosis supported Prior Level of Function Skilled Intervention Goals Progressed Patient’s Response / Progress

17 Diagnosis Supported Objective measures, tests, and assessments Medical History Medical Questionnaire Physician’s Order includes diagnosis

18 Diagnosis Supported Examples by discipline PT Treatment Dx: Gait Abnormality –Objective tests: TUG, DGI, Tinetti, Berg –Medical History/Medical Questionnaire: prior CVA in 2003 OT Treatment Dx: Lack of Coordination –Objective tests: PPT, 9-hole peg Test, etc. –General Medical Questionnaire: History of Athritis ST Treatment Dx: Cognitive-Linguistic –Objective tests: SPMSQ, GDS, BCRS, etc. –Physician order: Dementia diagnosis SN Dx: COPD –Objective tests: Borg RPE (Rate of Perceived exertion) –Medical History: COPD

19 Where to document Diagnosis - HCHB

20 Where to Document Diagnosis – Outpatient and HCC Evaluation Certification Form, Page 1, #’s 15-16

21 Prior Level of Function Describes the patient’s highest functional abilities prior to the onset of their complaint, incident or decline in functional capacity –Usually within 3 months of the onset Must be discipline and treatment specific –i.e. ST describes prior communication abilities, while OT describes prior ADL planning abilities since that is their focus of treatment Include PLOF for each functional focus or deficit that is being treated

22 Prior Level of Function Examples PT –“Pt. amb. Independently 1000’ with std. cane on in/outdoor surfaces without loss of balance” OT –“Pt. donned/doffed clothing independently without shortness of breath, fatigue or loss of balance in less than 5 minutes” ST –“Pt. tolerated unrestricted diet consistency without signs/symptoms of aspiration” SN –“Pt. managed medications independently”

23 Where to document PLOF - HCHB PATIENT NOT DEEMED HOMEBOUND OTHER/NARRATIVE FORM: Q: INDICATE REASONS CLIENT IS HOMEBOUND:... - A: OTHER - SPECIFY INDICATE OTHER HOMEBOUND STATUS REASON: TYPE: TEXT - MULTISELECT: N N/A [INSURANCE] HEALTH HISTORY - 3 (ADD-ON: OT/PT/ST) NEW *Effective From 12/08/2010 To 01/01/2100 INDICATE PATIENT PRIOR LEVEL OF FUNCTION - PRIOR TO THIS EPISODE OF ILLNESS (MARK ALL THAT APPLY): TYPE: LIST - MULTISELECT: Y INDEPENDENT IN COMMUNITY INDEPENDENT AT HOME INDEPENDENT WITH USE OF ASSISTIVE DEVICES OTHER/NARRATIVE FORM: Q: INDICATE PATIENT PRIOR LEVEL OF FUNCT... - A: OTHER (SPECIFY) INDICATE OTHER PRIOR LEVEL OF FUNCTION: TYPE: TEXT - MULTISELECT: N ENVIRONMENTAL - 9 (ADD-ON: OT), (D/C FROM DISCIPLINE: OT), AND (VISITS: OT) *Effective From 12/08/2010 To 01/01/2100 ARCHITECTURAL ASSESSMENT/HOME EVALUATION ASSESSED? TYPE: LIST - MULTISELECT: N NO FORM: ENVIRONMENTAL - A: 0 - NO INDICATE REASON ARCHITECTURAL ASSESSMENT/HOME EVALUATION NOT ASSESSED: TYPE: LIST - MULTISELECT: N NOT APPROPRIATE AT TIME OF EVALUATION NOT APPLICABLE YES FORM: ENVIRONMENTAL - A: 1 - YES

24 Where to Document PLOF – Outpatient and HCC Outpatient/HCC Evaluation Certification Form: Page 2, Space #20

25 Skilled Intervention MUST be documented in each visit note All services documented must show a level of skill and complexity that only a skilled therapist, therapy assistant or nurse can provide Should include specific goal-directed actions the therapist or nurse provided during the visit to achieve functional outcomes

26 Skilled Intervention Examples “PT instructed patient in safe, sit-to-stand transfer sequence, pt. return demonstrated with 50% accuracy” “ST facilitated production of multi-syllabic words in isolation with focus on accuracy” “OT designed compensatory tools to aid in appropriate sequencing of dressing tasks” “SN instructed use of Medication reminder tool to aid in independence with medication management”

27 Skilled Intervention Action Words

28 Where to document Skill - Outpatient and HCC

29 Where to document Skill - HC HB Login to PointCare –Tap on the PointCare application on the device – review agent ID, password, version and server –Interventions for today’s visit. What you taught, what you did. Interventions are disease-specific and were selected at the SOC visit –All interventions appear at all therapy/nursing subsequent visits unless an exception code is used to discontinue them –Therapy Goals/Status – Therapy/Nursing specific items are tracked from status/goals perspective

30 Short Term Goals Smaller objective, functional goals that will be progressed and revised throughout the POC to achieve the LTG Short-Term Goals Progressed

31 Listed with anticipated time for completion Written as “patient will... ” describing expected outcomes Objective/measurable (e.g. time, level of assistance, number of errors, etc.) Functional (Must answer “For what functional purpose does this goal help the patient achieve”) Related to the care setting (IP/OP/HH) and expected D/C location Short-term Goals Progressed (cont.)

32 Short – Term Goals Progressed Examples Outpatient: “In 2 weeks, pt. will amb. 150’ with 4w/w supervised with minimal shortness of breath to increase functional ambulation tolerance” –How would you change or progress this goal? Distance Device Level of supervision Amount of perceived shortness of breath (Borg scale) Ambulation destination (bathroom, dining room, grocery store, etc.) Home Health: “In 3 visits, pt. will verbalize 2/5 safety precautions for safe O2 use in the home” –How would you change or progress this goal? Number of items verbalized correctly Demonstration versus verbalization

33 Home Health vs. Outpatient Goals Home Health Safety in home with ADL function Pain management Stabilize medical condition Perform ADLs safely with use of adaptive devices/assist Judgment related to safety Outpatient Ability to maximally function in/out of home environment Increased strength/ endurance for outside activity Maximize independence with ADL function Higher level executive function

34 Where to Document Short- Term Goals in HCHB The NDPs (Nursing Diagnoses/Problem Statements) establish each discipline’s 485 orders and 485 goals as well as set up the care plan for all future visits in the episode NDPs are established by the evaluating RN or therapist in the field, however, office users can also edit NDPs from two different screens : (1) While Reviewing Evaluation Documentation visits; or (2) Via Clinical Input by right clicking on the visit from the applicable Visit Note. If the second is used, the patient’s care plan is updated the day after the Interventions and Goals were regenerated in HCHB Interventions and Goals will be generated (or regenerated if the NDP is edited) for all visits of that discipline that have not yet been started

35 Where to Document Short-Term Goals in Outpatient/HCC Evaluation Certification Form: Page 2, #24

36 Patient’s Response / Progress Documented Response and Improvement is evidenced by –Successive objective measurements –Subjective measures (evidence-based) Visual Analog Scale (VAS) Documented in progress notes and summaries

37 Patient’s Response / Progress Examples PT: “Pt. demonstrated increased tolerance of UE exercises using 1lb. with increased repetitions to 15 OT: “Pt. requires 50% less verbal cues /prompting for safety and sequencing of dressing tasks. ST: “Pt. improved short-term recall to from 5/10 to 9/10 items” SN: “Pt. now demonstrates 5/5 safety precautions in use of O2 in the home.”

38 Where to Document Patient Response/Progress - HCHB Login to PointCare (Tap on the PointCare application on the device – review agent ID, password, version and server) Therapy Goals/Status - Therapy-specific items are tracked from status/goals perspective. Only select those items necessary for the patient. –If the goal and the status are the same, a red exclamation mark will appear in the carryover status. Carryover if you want to continue to monitor that item. –Can enter remarks. Tap set remark, enter remark, tap set remark. –Goals can be updated by a therapist only – not by an assistant – This becomes the “O” of the soap note – objective Therapy Assess/Plan – Free text boxes. Becomes the “A” and “P” part of the SOAP note – assessment / plan. Give a short assessment of the visit and the plan for next visit

39 Where to Document Patient Response/Progress – Outpatient and HCC Daily Visit Notes –Pt. Comments –Weekly Summary of Progress –Exercise Record 14-day Progress Summary Discharge Summary

40 Patient’s Response / Progress Example – Exercise Record Note progress in repetitions, seconds, etc.

41 Final Thoughts Good Documentation tells the patient’s story. In any care setting... we can demonstrate the value and necessity of our service by describing the patient’s functional decline AND how the skilled services we provide helps to meet their needs, achieve meaningful independence, and quality of life. Remember: Documentation is our Best Defense!!

42 Innovative Senior Care Rehabilitation…Fitness…Education


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