Download Nursing_Documentation_02_11

Nursing Documentation to Support
Medical Necessity
Lisa Werner, 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
• 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 Order
• 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.)
 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:
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Vitals
Medications
Allergies
Social history
 Review of systems:
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Cardiovascular
Musculoskeletal
Neurological
Pulmonary
Gastrointestinal
Renal/Genirourinary
Skin
Nutrition
Plan of Care
• Nursing Admission
Assessment:
 Concludes with a problem
list
• Impaired mobility
• Self-care deficits
• Altered urinary
elimination
• Altered bowel
elimination
• Potential for injury
• Activity intolerance
•Impaired skin integrity
•Impaired communication
•Impaired swallowing
•Altered nutrition
•Pain
•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:
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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
• 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
throughout 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, MBA, MS, CCC-SLP
[email protected]
202-588-1766