Presentation on theme: "Documentation: Back to the Basics – Using the Nursing Process"— Presentation transcript:
1 Documentation: Back to the Basics – Using the Nursing Process Problem IdentificationDocumentation: Back to the Basics – Using the Nursing ProcessPresented by: Arlene Maxim, RN-President/FounderA.D. Maxim Consulting, LLC.
87 What Can Go Wrong? (cont.) Example: Therapist failed to prepare complete & accurate clinical progress notes, including discharge summaries according to Agency policy resulting in late or missing documentation.Agency policy indicated documentation is due every two weeks with payroll. At the time of collection, there were late docs, Patient records missing task instructions, and additionally a Patient was discharged to hospice. SN services had a discharge summary on file, but PT did not. Another Patient’s discharge summary failed to discuss Patient progress toward goals & Patient condition at time of discharge
107 What Can Go Wrong?The surveyor may find an aide performing services during a home visit for which he/she is not properly trained
108 484.36b4(ii) Competency Determination G 220 A home health aide is not considered to have successfully passed a competency evaluation if the aide has an unsatisfactory rating in more than one of the required areas
109 G221 Documentation of Competency Determination §484.36(b)(5) Standard: Documentation of Competency Evaluation. The HHA must maintain documentation which demonstrates that the requirements of this standard are met
110 G223 Documentation of Competency Determination G223 §484.36(c) Standard: Assignment and Duties of the Home Health Aide(1)-The home health aide is assigned to a specific patient by the registered nurseG224 (Rev.) §484.36(c)(1) - Written patient care instructions for the home health aide must be prepared by the registered nurse or other appropriate professional who is responsible for the supervision of the home health aide under paragraph (d) of this section
111 G225-G227 §484.36(c)(2) DutiesThe home health aide provides services that are ordered by the physician in the plan of care and that the aide is permitted to perform under State law226 §484.36(c)(2) - The duties of a home health aide include the provision of hands-on personal care, performance of simple procedures as an extension of therapy or nursing services, assistance in ambulation or exercises, and assistance in administering medications that are ordinarily self-administeredG227 §484.36(c)(2) - Any home health aide services offered by an HHA must be provided by a qualified home health aide
112 G228 §484.36(d) Supervision1) - If the patient receives skilled nursing care, the registered nurse must perform the supervisory visit required by paragraph (d)(2) of this section. If the patient is not receiving skilled nursing care, but is receiving another skilled service (that is, physical therapy, occupational therapy, or speech-language pathology services), supervision may be provided by the appropriate therapist
113 SupervisionG229 (Rev.) §484.36(d)(2) - The registered nurse (or an other professional described in paragraph (d)(1) of this section) must make an on-site visit to the patient’s home no less frequently than every 2 weeks. G230 §484.36(d)(3) - If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy or speech-language pathology services, the registered nurse must make a supervisory visit to the patient’s home no less frequently than every 60 days. In these cases, to ensure that the aide is properly caring for the patient, each supervisory visit must occur while the home health aide is providing patient care
114 Supervision G-231-G233References Aides not directly employed by the Agency and Personal Care AttendantsRefer to COPs
170 Wound Care (cont.)Where the physician has ordered appropriate active treatment (e.g., sterile or complex dressings, administration of prescription medications, etc.) of wounds with the following characteristics, the skills of a licensed nurse are usually reasonable and necessary:Open wounds which are draining purulent or colored exudate or have a foul odor present or for which the patient is receiving antibiotic therapyWounds with a drain or T-tube with requires shortening or movement of such drains
180 – Venipuncture (cont.)However, if a beneficiary qualifies for home health eligibility based on a skilled need other than solely venipuncture (e.g., eligibility based on the skilled nursing service of wound care and meets all other Medicare home health eligibility criteria), medically reasonable and necessary venipuncture coverage may continue during the 60-day episode under a home health plan of care
192 The Nursing Process as a “Tool for Critical Thinking” Critical thinking skills are essential in nursing because they are the basis for learning to prioritize and make decisions5 steps to using thinking that is “purposeful”:What are you trying to figure out?What do you think can be accomplished?What is known about the problem?What are the concepts, ideas, and theories that we use in finding a solution to the problem?What are the consequences for our actions?
194 Skills of Critical Thinking The skills that are needed include: Interpretation – The ability to understand and explain the meaning of information or an eventAnalysis – The investigation of a course of action based on objective and subjective dataEvaluation – The process of assessing the value of the information obtained. Is it credible, reliable, and relevant? This skill is also applied in determining if desired outcomes have been reached
195 Skills of Critical Thinking Explanation – The ability to clearly and concisely explain one’s conclusionsThe nurse should be able to provide sound rationale for his/her answers.Self-regulation – Involves monitoring one’s own thinkingThis means reflecting on the process leading to the conclusions.The individual should self-correct the thinking process as needed, being alert for biases and incorrect assumptions.
218 IMPLEMENTATION – Writing a Nursing Note ALL documentation must have:Legible SignatureDate of SignatureLate entries must be properly entered and dated with date of entryCorrections should be one line through error, date, initials and correction documented
222 EVALUATION – Is the Plan Working? DISCHARGE? Are they ahead of plan? May need to discharge early, would need to discuss and provide discharge notices and notify the physicianRECERTIFICATION? Are they making slow progress? Document barriers to progress – education level or low literacy, poor coping skills, multiple caregivers involved, changes in medication or treatment
248 Orders for Care: Establishing Frequencies Be sure to include all disciplines ordered on referral!Be sure to document if the patient refuses a discipline that was ordered and that the physician was notified!
250 Orders for Care: Establishing Frequencies (cont.) Ordering Aide Services:Must be reasonable and necessaryMust include specific orders for careMust be supervised at least every 14 daysRECOMMENDED EXAMPLE:“HHA 3x week x 2; then 2x week x 7 for personal care and assist with exercises prescribed.”
253 KEEP IT SIMPLE - Establishing Goals (cont.) PUTTING GOALS FIRSTRules for GOAL Setting:Be RealisticBase each goal on CURRENT PROBLEMS identified during assessmentMake sure each goal is measureableBe sure each goal is clearly articulatedREMEMBER: Interventions are selected ONLY after goals and predicted patient outcomes are determined!!!
254 KEEP IT SIMPLE - Establishing Goals (cont.) Problem IdentificationKEEP IT SIMPLE - Establishing Goals (cont.)Make a LIST!!!!!Keep orders to a minimum-based on goals establishedOrders must be related to diagnosis codes establishedInclude Process Measures (OASIS Synopsis Items ) when applicable.Orders should be your ROADMAP to positive patient outcomes
256 Problem Identification KEEP IT SIMPLE - Establishing Goals (cont.)Parameters should be specific to the patients condition!For Example:Patient admitted to Agency new to insulin-BS runningNurse orders parameters for notifying physician: Notify phys. BS <70 or >200How often will you be calling Doctor????Use good clinical judgment when establishing parameters!
257 KEEP IT SIMPLE - Establishing Goals (P.S.) Be SURE the Clinician taking verbal orders for the start of care SIGNS AND DATES Box 23 on the 485/plan of careMake SURE the Physician signs and dates the plan of care - the Agency may NO LONGER date the date of receipt as a replacement for the physician’s failure to date orders!!
260 Problem Identification Other Documentation Issues1. Medication documentation - identify new and changed medsUpdate as frequently as necessaryBe sure to have correct dates re: Start and Discontinuing medsIf paper documentation - PRINT medicationsHighlight discontinued medications using yellow highlighterAntibiotics require start and end date on the order and on med profile!Keep LOGS for multiple changing meds - i.e., Insulin, Coumadin, etc.Be sure to have procedure for reconciliation of medications when disciplines other than nurse is performing SOC assessment
261 Other Documentation Issues (cont.) Coordination of Services - write a policyPlan coordination of services with all disciplines on a regular basisPatient Recovery in home health care is a TEAM effort!Include what you discussed (should be problem/goal driven); and who provided input
262 Record Keeping Principles Medicare Benefit Integrity Manual Pub Transmittal 442 (January 8, 2013)“Regardless of whether a documentation, submission originates from a paper record or an electronic health record, documents submitted to (medical reviewers) containing amendments corrections or addenda must:Clearly and permanently identify an amendment, correction or delayed entry as such, and;Clearly indicate the date and author of any amendment, correction or delayed entry, and;Not delete but instead clearly identify all original content.”