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Nursing Documentation to Support
Medical Necessity
Lisa Werner Bazemore, MBA, MS, CCC-SLP
Director of Consulting Services
Medical Necessity
Basic Principles
 Service must be reasonable and necessary (in terms of efficacy
and, duration, frequency, and amount) for the treatment of the
patient’s condition
 It must be reasonable and necessary to furnish the care on an
inpatient hospital basis, rather than less intensive facility such
as a Skilled Nursing Facility, or on an outpatient basis
Medical Necessity
Medical Necessity
 Services are relevant to a patient’s diagnosis, symptoms,
condition or injury
 Services provided are within the standards of practice for a
specific condition or diagnosis
 Services require the skills of the specific professionals within
your setting
 Services that are provided in your setting possibly would not be
furnished in the same quality or quantity or time frame in
another setting
 Services treat a condition which could result in physical or
mental disability
Team Documentation
What can the non-physician provider do to support medical
necessity?
 Ensure documentation is legible and easy to navigate.
• Auditors review many charts each day. They will not struggle to
decipher and organize therapy documentation to establish the
medical necessity of services.
 Use only medically accepted abbreviations
 Follow good medical integrity practices for corrections and for
documenting late entries.
Team Documentation
Proving necessity of the skilled service:
 Reviewers look for evidence that the patient requires continued
skilled services. This is shown through the treatment/progress
notes:
• Write progress notes that clearly explain the skilled services
delivered in each treatment session.
Plan of Care
Medicare wants to see the treatment plan is determined by
and coordinated by the physician
 Admission Orders
• Should indicate all therapeutic disciplines ordered – INCLUDING
Rehabilitation Nursing
 If “evaluate and treat” must follow up with a clarification order
 If specific interventions are indicated the disciplines MUST have
them in their plan of care
 Clarification Orders
• Need to be signed by the physician
• Should indicate frequency and duration as well as all possible
interventions
Plan of Care
Plan of Care is a individual discipline or multidisciplinary
document that outlines the patients problems, proposed
interventions and goals.
The Plan of Care serves many needs:
 Communication
 Meeting requirements of
• Medicare & Insurance Companies – multidisciplinary team
• JCAHO – Prioritization of problems
• CARF – Reflects the goals of the persons served
• Facility – ???
Plan of Care
Purpose of the plan of care:
 To communicate patient goals & expected outcomes to the
team & family
 To communicate to the patient & family what they can expect
each team member to be doing to help meet the
interdisciplinary goals
 To communicate interdisciplinary treatment goals, expected
outcomes & summary of progress to the patient
 To communicate interdisciplinary treatment goals, expected
outcomes, & summary of progress to payer sources
 To provide a means to alter the initial treatment plan, as
appropriate
 To facilitate family participation in the rehab process
 To document the patient’s progress in his/her rehabilitation
program
Plan of Care
Purpose of the plan of care: (cont’d)
 Documentation that is interdisciplinary
• Created by all components of the rehab treatment team
• Collaboration among team members, including patient, determines
team goals
• Is agreed upon by all parties
 Derived from the team assessment and patient expectations
 Clearly identifies long and short term goals
 Defines how disciplines share responsibilities for the efficient &
effective goal attainment by the patient
 Supports the need for intensive inpatient rehab services
Plan of Care
How does the information flow?
 Pre-admission screening form gathers information on actively
treated conditions and history of the present illness
 Physician reviews pre-admission screening and acute records
 Physician does assessment
 Clinicians reference pre-admission screening, acute records,
and physician documentation prior to assessing the patient
 Clinicians do assessments
 Clinicians develop discipline specific goals
 Team coordinates to align patient and discipline specific goals
into overarching team goals
 Team coordinates and implements a multidisciplinary plan of
care to achieve overarching team goals.
Plan of Care
How do you develop a plan of care?
 Physician plan drives the plan of care for clinicians
 All clinicians document consistent findings
 Goals are clear, measurable, functional
How do you document the plan of care?
 All clinicians document on the same form (Best Practice)
 Everyone is aware of the team goals and supports them
through treatment
Plan of Care
Establishing barriers:
 Plan of care should answer these questions:
• Why does the patient need a stay in inpatient rehabilitation?
• What difference will inpatient rehabilitation make in this patient’s
quality of life?
 Problem list:
• List the problems requiring post-acute services
• Indicate which professionals will work on reducing the barriers
• Set goals for how much progress will be made
• Indicate time frame for resolving the barriers
Plan of Care
Framework of the plan of care:
 Roles:
• Neuropsychology
• Nursing
• Nutrition
• Physical Therapy
• Occupational Therapy
• Social Work
• Speech Therapy
• Therapeutic Recreation
 Each clinician has discipline specific things to work on
 These tasks overlap with other clinicians
 How do you represent this on your plan of care?
Plan of Care
Goal setting:
 Team goals (long-term)
• Represent what it will take for the patient to reach their discharge
goal
• Will require care or carry-over from the team to achieve
 Discipline specific goals (short-term)
• Should link to long-term team goals
• Must be objective
Plan of Care
Nursing Admission Assessment:
 Includes a review of current
situation:
 Review of systems:
• Cardiovascular
• Vitals
• Musculoskeletal
• Medications
• Neurological
• Allergies
• Pulmonary
• Social history
• Gastrointestinal
• Renal/Genirourinary
• Skin
• Nutrition
Plan of Care
Nursing Admission Assessment:
 Concludes with a problem list
• Impaired mobility
• Impaired skin integrity
• Self-care deficits
• Impaired communication
• Altered urinary elimination
• Impaired swallowing
• Altered bowel elimination
• Altered nutrition
• Potential for injury
• Pain
• Activity intolerance
• Altered thought process
• Unilateral neglect
• Ineffective airway clearance
• Others?
Plan of Care
Nursing Admission Assessment:
 Consideration: IRF specific assessment vs. house-wide
assessment
• What are the differences?
 Review of current status?
 Review of systems?
 Problem list?
• Where does it come together?
 Plan of Care
• How does it come together?
 Use the findings in the assessment to develop goals
 Determine what is most important to the patient
 Use judgment to assess the factors that will most significantly
impact the patient’s ability to return to independence
Plan of Care
Sample nursing goals:
 Patient will be continent of bladder/bowel ____ % of the time.
 Patient will remain free from UTI.
 Patient will understand and comply with ____diet restrictions.
 Patient will improve/maintain protein status.
 Patient will improve/maintain oral intake by consuming ____ %
of meals.
 Patient will improve/maintain weight at ____ % of ideal body
weight.
 Patient will meet nutritional needs to promote wound healing.
 Patient/caregiver will verbalize understanding and demonstrate
pressure relief techniques.
 Patient will understand and demonstrate pain relief techniques.
Plan of Care
Team Admission Assessment:
 Social Work/Case Management
• Prior level of function
• Living situation and needs
• Equipment haves and have nots
• Emotional concerns
• Preferences
• Discharge plan
• GOALS!
Plan of Care
Sample social work/case management goals:
 Patient will be discharged _________ with the necessary
equipment.
 Patient will be discharged with the necessary services.
 Patient/caregiver will be educated on the patient’s condition and
needs prior to discharge.
 Patient/caregiver will demonstrate an understanding of
appropriate and available community resources.
Plan of Care
Team Admission Assessment:
 Occupational Therapy –
• Eating
• Grooming
• Bathing
• Dressing/clothing management
• Toileting
• Toilet transfers
• Tub/shower transfers
• Home management
• Cognition
• Upper extremity range of motion and strength
• Sensation, tone, balance, motor planning and control, perception
• Pain
Plan of Care
Sample Occupational Therapy goals:
 Patient will feed self with ___ level of assistance.
 Patient will perform grooming tasks seated/standing with ___
level of assistance.
 Patient will follow ___ step command to assist with ADLs ___ %
of the time.
 Patient will shower/sponge bath with ____ assistance
seated/standing with ______ assistive device and _____ DME.
 Patient will complete upper body (or lower body) dressing with
_____ assistance using ______ assistive device.
 Patient will transfer to/from toilet with ______ assistance using
_____ equipment.
 Patient will verbalize solutions to safety situations ____ % of
the time.
Plan of Care
Team Admission Assessment:
 Physical Therapy –
• Bed mobility
• Transfers
• Locomotion
• Stairs
• Sensation, tone, balance, motor planning and control, perception
• Pain
• Ability to participate and learn
Plan of Care
Sample Physical Therapy goals:
 Patient will perform bed mobility with ____ assistance.
 Patient will transfer to/from the bed to wheelchair/stand with
____ assistance and ____ assistive device.
 Patient will transfer to/from the car with ____ assistance and
_____ equipment.
 Patient will walk/operate wheelchair _____ feet with ____
assistance using ______ device.
 Patient will negotiate ___ stairs/curbs with ____ assistance
using _____ equipment.
Plan of Care
Team Admission Assessment:
 Speech Therapy –
• Eating and swallowing
• Comprehension
• Expression
• Problem solving
• Memory
• Speech intelligibility
• Executive functioning
• Pain
• Ability to learn
Plan of Care
Sample Speech Therapy goals:
 Patient will consume least restrictive diet without signs or
symptoms of dysphagia ____ % of the time.
 Patient will exhibit functional lingual and labial strength and
range of motion.
 Patient will comprehend complex information at the
word/sentence/conversation level _____ % of the time.
 Patient will answer yes and no/open ended questions to
improve communication with others ___ % of the time.
 Patient will communicate needs at ____ level to all partners
_____ % of the time.
 Patient will demonstrate short-term memory skills at ____
level.
 Patient will remember treatment schedule and visitors with ___
% accuracy.
Plan of Care
Team Admission Assessment:
 Neuropsychology –
• Adjustment
• Social interaction
• Memory
• Problem solving
• Pain management
Plan of Care
Sample Neuropsychology goals:
 Patient will demonstrate
problem solving skills in all
disciplines with ____ %
accuracy.
 Patient will remember
treatment schedule and
visitors with ____ %
accuracy.
 Patient will verbalize
solutions to safety situations
____ % of the time
 Upon discharge patient will
have participated in 1 Ther
Rec program and / or
demonstrate good social
skills with patients and staff.
 Patient will have decreased
depression by ___ %.
 Patient will have decreased
anxiety by ___ %.
 Patient will demonstrate
increased motivation to
participate in activities.
 Patient will increase and
apply their strategies for pain
management.
Plan of Care
Team Admission Assessment:
 Therapeutic Recreation –
• Community reintegration
• Social interaction
• Home management
• Adjustment to disability
• Orientation
Plan of Care
Sample Therapeutic Recreation goals:
 Patient will remember treatment schedule and visitors with
____ % accuracy.
 Patient will verbalize solutions to safety situations ____ % of
the time
 Upon discharge patient will have participated in 1 Ther Rec
program and / or demonstrate good social skills with patients
and staff.
 Patient will be able to re-enter the community to enjoy /
perform leisure activities based on current abilities.
 Patient will be able to perform home management tasks based
on current abilities.
Plan of Care
Establishing team goals:
 Must be important to patient, his/her family, and other
members of the team
 Must be associated with identified problem
 Must have an impact on the patient’s health and quality of life
 There must be strengths and resources available that can be
mobilized to deal with the problem
 Must be able to identify what needs to be done, who will do it,
and when it will happen
 Must be able to identify an expected outcome that can be
expressed in measurable terms and with an expected
timeframe
 Must be complex enough to require the skills and commitment
of multiple members of the team
Plan of Care –
Team Goals
Toileting: Ms. Smith will toilet with supervision.
 OT will address toileting: clothing management and hygiene
 PT will address ambulation with the walker in cluttered areas
 ST will assist with developing a communication system to assist
the patient with communicated the need to toilet.
 Nursing will follow through with therapeutic techniques learned
in PT/OT during the evening and the service aide will ask the
patient if he or she needs to toilet when rounding
 MD will order timed voids and adjust medications
 All disciplines will enforce fluid restrictions, communicate
accidents, and participate in assisting the patient with timed
voids
Plan of Care –
Team Goals
Family Education: Mr. Brown’s family will demonstrate the
ability to safely assist the patient with self-care and mobility
with supervision prior to the next care team meeting.
 ST will perform education on modifications to Mr. Brown’s diet
 OT will perform education on assisting the patient with lower
body dressing and toileting
 PT will perform education on assisted ambulation
 Nursing will perform education on medication management
 Case Management will schedule family education sessions
 All disciplines will complete thorough documentation on
education completed noting barriers to effective education
Plan of Care –
Team Goals
Effective Communication: Mr. Smith will demonstrate
the ability to follow one step commands from his spouse 75%
of the time.
 ST will provide education during the care team conference on
effective modes of communication with Mr. Smith who has
severe receptive aphasia
 ST will initiate education on these strategies with the family
 All team members will model these communication strategies
with the patient to improve the patient and family’s ability to
effectively communicate
Plan of Care –
Team Goals
Bladder Management: Ms. Jones will demonstrate bladder
continence 100% of the time.
 Nursing will develop and implement a timed void schedule.
They will also educate the patient and family to the rationale
and goal.
 Therapies will adhere to the timed void schedule while the
patient is in therapy.
 Therapies will reinforce education provided by nursing when
working with the patient/family.
 Nutrition will work with the physician to limit or eliminate
bladder stimulants like caffeine.
 The physician will review the patient’s medications to see if any
are likely to induce frequency and eliminate or change if
possible.
Plan of Care
Next steps
 Plan of care should be the guiding force for treatment decisions
throughout the stay
• Update weekly at team
• Ensure that team is on target with established goals
• Reorient team to long-term goals if treatment plan seems to be
taking a different course
• Adjust plan of care goals as necessary
Team Documentation
Ongoing documentation of skilled services:
 Use skilled terminology and objective measurements in
documentation to show functional progress and improved safety
as a result of the delivery of skilled intervention.
• Examples include:
 Assessment of performance
 Adaptation of the task or environment
 Training in the use of adaptive equipment
 Use of specialized treatment techniques
 Adjusting the treatment program as the patient's condition changes
 Providing analysis of performance and skilled feedback on
performance
Team Documentation
Ongoing documentation of skilled services:
 Document that the patient is able to follow directions, retains
the skills learned, and shows carryover of the learned skills into
other functional areas.
 Justify the need to continue treatment based on progress,
treatment goals, and functional level needed at discharge.
 Explain any setback or lack of progress but supporting that the
patient retains good potential to achieve the set goals.
Team Documentation
Ongoing documentation of skilled services:
 Specify when recommended orthotics or adaptive equipment
arrived and were fitted, and the patient's response.
 Explain complications such as the development of pressure
areas after application of an orthotic to show improved patient
safety from skin breakdown.
 Address patient, family, and caregiver training and successful
carryover of the tasks taught.
 Ensure that documentation by other disciplines involved with
the patient corroborates changing functional abilities as a result
of clinical intervention.
Team Documentation
Documentation near discharge:
 Clinicians should train the patient, family, or caregivers during
the entire course of treatment to facilitate carryover of skills
taught in treatment.
 The stay may not be continued after a plateau in performance
skills has been reached for the sole purpose of training
caregivers.
 Treatment should not automatically be continued because
skilled placement can not be found.
• Continued treatment can be supported if discontinuing treatment
would compromise the patient's safety or health.
Team Documentation
The goals of the team documentation are:
 Tell the story of the patient’s stay
 Communicate why you made the treatment decisions
for care rendered
 Indicate how the patient progressed
 Present the barriers to discharge or safety concerns
hroughout the stay
 Let the service provider treating the patient next know
what to expect
Team Documentation
Team has an ongoing opportunity to document medical
necessity. This is achieved by documenting:
 That services needed are of a complex nature that they require
a licensed clinician
 Services are consistent with diagnosis, need, and medical
condition
 Services are consistent with the treatment plan
 Services are reasonable and necessary
 Patient is making progress towards reasonable goals
Nursing Documentation
Rehabilitation nursing services are necessary 24/7
 Nursing plan addresses rehabilitation needs of the patient
 Supports medical management as laid out by physician
 Addresses education needs of the patient
 Establishes continuity of care among the team
Nursing Documentation
Daily Documentation:
 Flow Sheets
 Functional Independence Measure Scoring
 Narrative notes that state
• Care rendered
• Patient’s response to care
• Patient’s performs in areas where functional deficits exist
 Transfers
 Self care
 Communication/cognition
 Locomotion
• Education provided
• Patient/family’s response to education
Nursing Documentation
Care rendered and patient’s response to care:
 List types of care provided to patients during:
• Day shift
• Evening shift
• Night shift
 We state that our patients require the skills of a rehab nurse 24
hours a day.
 Does this sound like rehab nursing?
• “Patient resting comfortably in bed.”
• “Patient eating dinner with spouse at bedside”
• “Patient voices no complaints”
• “Doctor in to see patient, no new orders”
Nursing Documentation
Care rendered and patient’s response to care:
 How do we talk about skin integrity?
• Checked patient q2 hours for position of hemiparetic arm.
Repositioned arm each time because patient is neglecting left arm.
• Reviewed pressure relief techniques with patient and caregiver this
evening. Patient continues to forget to self-initiate repositioning
when in his wheelchair.
• Healing noted by reduction of sacral wound size to xx cm. Patient
observed using pressure relief techniques while in wheelchair today.
• Other examples?
Nursing Documentation
Care rendered and patient’s response to care:
 How do we talk about pain?
• Patient is maintaining a pain level of 3 by initiating the request for
medication prior to therapy without reminders.
• Patient was supervision with transfers this shift, which he reports is
related to pain reduction.
• Patient was unable to participate in therapy sessions this morning
due to extreme pain. Continuing to monitor pain levels to achieve
control that will allow participation in this afternoon’s program.
• Other examples?
Nursing Documentation
Care rendered and patient’s response to care:
 How do you talk about bladder and bowel elimination?
• Change of dosage of Detrol resulted in reduced bladder leakage.
Patient did not have any accidents this shift, which is significantly
improved from 2/21 when the patient experienced 3 bladder
accidents in one shift.
• Patient had hard stool today. Will encourage increased fluid intake
to 200 cc/hr and notify team to assist with fluid reminders.
• Due to frequent accidents, a q2 hour bladder program has been
initiated.
• Patient alerts nurses for toileting at the top of the even hours in
keeping with his bladder protocol.
• Other examples?
Nursing Documentation
Care rendered and patient’s response to care:
 How do we talk about safety?
• Patient attempted to get up to go to the bathroom without calling
for help. Patient was reminded of limitations due to his recent
surgery requiring him to be supervised with transfers and mobility.
Patient indicated understanding of how to call for assistance.
• Due to increased confusion tonight, patient required frequent
observation from nursing. He required checking every 30 minutes
for safety. Patient required redirection about half of the time.
• Patient and family educated on the importance of close monitoring
for basic needs to decrease the risk of the falls as patient tried to
complete task unsupervised.
• Other examples?
Nursing Documentation
Functional Status:
 Notes should address functional performance in:
• Functional Independence Measure Flow Sheet
• Narrative Notes
• Shift Report
 Keep your team goals in mind. How is the patient performing
against established goals?
 Include comments on the barriers to the patient’s independence
Nursing Documentation
Functional Performance Examples:
 Patient showed no signs and symptoms of aspiration while
taking noon meds with nectar thick liquids.
 Patient required moderate assistance while transferring to the
toilet due to loss of balance.
 Patient was reminded to keep his feet on the floor while
transferring with sliding board as instructed by PT.
 Patient experienced a bladder accident due to a urinal spill.
Caregiver was needed to change the patient’s bed linens.
 Patient required moderate assistance while bathing this
morning due to increased pain. He was unable to wash lower
extremities, buttocks, and perineal area.
 Others?
Nursing Documentation
Family/patient education examples:
 Patient has not exhibited improved performance with external
cath placement. Family is discouraged, but willing to continue
education in order to assist the patient at home.
 Patient demonstrating signs of difficulty adjusting to disability.
Nurse provided support group information to patient and wife.
 Patient and family educated on blood sugar testing and
monitoring. Family performed task with nurse supervising.
More instruction with finger sticks is required.
 Patient/family continues to require education regarding
medication administration and signs/symptoms of disease
exacerbation.
Nursing Documentation
Showing progress:
 At least weekly, return to the established team goals.
 Note where progress has been made by stating current status
compared to prior status.
 Review previous narrative notes to determine what burden of
care was present earlier that is now resolved.
 Indicate how nursing interventions resulted in a positive
outcome.
Nursing Documentation
At least weekly, a summary of the patient’s progress
should be documented.
 Document progress toward goals
 Detail barriers to achievement of goals
 Describe changes to the plan of care as appropriate
 Describe patient’s response to treatment
 State the justification for continued stay on the rehab unit
Questions?
Lisa Werner Bazemore, MBA, MS, CCC-SLP
[email protected]
202-588-1766