1. SOCIAL SERVICES A QUALITY KEY

2. PRESENTED BY Rhonda Anderson, RHIA President, AHIS Anderson Health Information Systems, Inc. 940 W. 17 th Street, Suite B Santa Ana, CA 92706 Tel. 714-558-3887 Fax 714-558-13-2 Email office@ahis.net

3. TOP TEN KEYS TO QUALITY DOCUMENTATION KISS – Keep It Simple and Short Documentation System –Manual or automated, individualized to patient? –Does your records include pertinent data and follow the format/content requirements? Don’t repeat information from others Keep the records/documentation sequential/organized

4. TOP TEN KEYS -2 Timely, accurate, legible if manual; date, time entry and signed if automated Document completely and identify the patient clearly. Ensure documentations do not look like a “stamp” for all patients. Tell how you planned, what you did and the outcome Meet both State and Federal regulations

6. TOP TEN KEYS -3 Assessments – In the old and the new regulations, assessments are still a part of the planning and delivery of services. Accuracy and completeness of assessments mean the resident and the related family/support system information. (Of course consent of the patient is important because without that you really have no resource beyond the patient.)

7. WHAT IS THE GOAL OF SOCIAL SERVICES? MAXIMIZE Support and Adjustment – “Patient and family” –What does that mean to you? –Have you determined this with your interdisciplinary team? –Do your policies and procedures reflect this approach? –Have you included interest in transplant & f/up?

8. ASSESSMENTS Individualized Identify the patient’s past Disabilities aside from the ESRD issues Mental status previously and now Language barriers Past work life so the IDT can consider how that can be carried into today’s challenges Past compliance with food and nutrition

9. ASSESSMENTS -2 Family relationship and status Mental status in the past and currently observed, i.e., medication side effects and social impact Support system, i.e., family, friends, employer Resources needed, i.e., identification of transportation, equipment, caregivers, medications Etc…etc.-- different for each resident

10. ASSESSMENTS -3 Assessment is NOT only initial. It is an ongoing process as you see the patient, participate and assist the patient and family to participate in the treatment planning process. The initial assessment does assist with determining some of the immediate needs and barriers.

11. ASSESSMENT IS KEY! Initial and ongoing assessment

12. WHAT ELSE CAN I DO TO IMPACT QUALITY OUTCOMES? To name a few: –Education –Counseling –Offering options –Working with the I.D.T which includes the patient, family and support system Make certain notes reflect this ongoing assessment and involvement, working with the patient and others

13. WHAT ELSE CAN I DO -2 Focus on the behavioral emotional issues and assist with calming that process Identify compliance with discussion with patient/family/others Anticipate problems and coordinate with I.D.T. Communicate and encourage participation in the plan of care

14. WHAT ELSE CAN I DO -3 Evaluate and provide ongoing education about: –The dialysis process –The family, social/work aspects and challenges –Awareness of the emotional toll –Psychosocial goals and life’s goals within the context of the dialysis needs –Follow up on transplant interest –Medication understanding of issues/w/nursing

15. WHAT ELSE CAN I DO -4 Feedback from the patient on understanding of: –Dialysis –Impact –Medications side effects on emotions –Sleep disturbance and approaches –Etc.

16. WHAT ELSE CAN I DO -5 Hospice services when that is applicable Emergency preparedness and travel support Teamwork!

17. WHAT IS THE OUTCOME? How do you measure what you have completed? A good job working with the patient, in that goals are met, if not met the I.D.T. is working with the patient.

18. WHAT IS THE OUTCOME? -2 Document the activities and actions –on a regularly scheduled basis, quarterly is a minimum; but not the expected –As activities and actions occur

19. COMPLIANCE WITH SURVEY STANDARDS What do surveyors expect? –Assessment – focus on the obvious – complete assessment!! –Care Planning – plan the findings from the I.D.T. assessment – involvement of the patient and dealing with the outcomes both positive and those where goals are not met –Ongoing documentation of assessing the patient and follow up.

20. COMPLIANCE WITH SURVEY STANDARDS -2 What do surveyors expect? (cont.) –Services supports – documented –Emotional and behavioral assessed and addressed not only in some cases with the patient, their family and staff providing the dialysis services.

21. IT IS NOT NEW MAXIMIZE PATIENT COMPLIANCE TO TREATMENT!!! And you do it so well –Now document all those good services you provide and show the outcome.

22. THANK YOU FOR ATTENDING