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Documentation:
Our Best Defense for Scrutiny
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
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”!
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
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
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
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
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
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
Who/What influences
Documentation
Standards/Requirements?
• 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
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
Essentials in
Documentation
• Technical Completion/Accuracy
• Medical Necessity of Skilled Intervention
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
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
Documentation Timeline
Expectations
Requirement
Home Health
Outpatient/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 Provided
On Date Services Provided
(no later than 9:00 A.M.
following day)
OASIS Completion
4 calendar days from SOC
N/A
Physician Signed &
Dated Evaluation Form
Must have by End of Episode Within 30 days from SOC;
or prior to billing of claim
should f/u at 14-day
assessment if not received to
ensure compliance
Daily Visit Notes
Point of Service / By Daily
Close
Point of Service / By Daily
Close
Top 5 Focus Areas for
Medical Necessity
•
•
•
•
•
Medical and Treatment Diagnosis supported
Prior Level of Function
Skilled Intervention
Goals Progressed
Patient’s Response / Progress
Diagnosis Supported
• Objective measures, tests, and
assessments
• Medical History
• Medical Questionnaire
• Physician’s Order includes diagnosis
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
Where to document
Diagnosis - HCHB

Diagnoses - Tap diagnoses.

To Add a Diagnosis - Tap “add.” Then tap “select…” next to code. The default
value for the diagnosis code is Home Health (most frequently used diagnoses). If
the diagnosis you are searching for does not appear within the search, tap on the
down arrow next to “Home Health” and change to “all.” The second box is a dropdown box that allows a search by ICD code or description. The default value is
ICD code. Tap on the down arrow to change from code to description. In the
third field, type the code or description and tap “search.” (Remember to use the
decimal if you are typing in a numeric code greater than 3 numbers).
Where to Document Diagnosis –
Outpatient and HCC
• Evaluation Certification Form, Page 1, #’s 15-16
1.
P atient’s Last Name
2 . Fir st Name
Simpson
Marge
5 . P r ovider Name
Innovative Senior Care
6 . DO B
01-01-1931
MI
Q
7 . A ge
81
8 . Sex
M
9 . C ur r ent Living Environment
F
AL IL
1 1 . H ospitalization Related to this Episode of C are
F RO M
TO
1 3 . SO C Date
0 1 /0 3/2012
NA
15.
Medical DX
1. IC D9 #_249.6
16.
Treatment DX
amb in room/apt
4 . P r ovider #
123-12-1234
000100
1 0 . P rior Living Environment (3 months prior)
AL
SNF
O ther_________
1 2 . P rior therapy (related to this condition/dx)
N /A
DA TE 12/1/11-12/28/11 HH PT/OT
RE S U LTS Improved transfers and mobility in apt
1 4 . A re the ser vices of a car egiver/family member r equired?
A ssistance prov ided for:
3 . H IC N
amb outside of room/apt
Description____Peripheral Neuropathy
Yes (If y es check below )
transfers
__________________
2. IC D9 #_250.93___ Description____DM
II uncontrolled
3. IC D9 #_250.72 __ Description____DM
peripheral circulatory disorder ______________
O nset Date _12/20/11___
O nset Date _12/20/11__
1. IC D9 #_781.2____ Description____abnormality of gait
_______________________
2. IC D9 #_781.3 ___ Description____Lack of coordination
3. IC D9 #_719.57___ Description____joint stiffness – bilateral ankles _________________
1 8 . Reason for Referral (state change in function) _
No
other ________________________________
17. Rehab
Potential
O nset Date _12/20/11__
O nset Date _12/20/11___
_ good____
O nset Date _12/20/11___
O nset Date _12/20/11___
Multiple falls related to loss of protective sensation. Does not have any compensatory techniques ________
P atient’s G oal _Ambulate with her cane without pain or fear of falling_________________________________________________________________________________
She has a History of PVD with several grafts to both lower exremities, recent discovery of several small vasular infarcts in her
brain with vision loss. She also has pain and stiffness in both shoulders and upper back area .
_____________________________
History related to this treatment _
Fully
Somewhat
Not at all
Yes (If Yes, how?__education provided on benefits/ risks of therapy _____________________________)
To w hat extent is pt/guardian aw are of therapy dx/prognosis?
C oncerns addressed?
Expectation for P ositive P rognosis
A w are of diagnosis
S timulable
M otiv ated
F amily S upport
P rev ious Interv entions w ere P ositiv e
No
N/A
O ther ___________________________________
3 step commands
Is a cognitiv e therapy referral needed?
Yes
N o Referral to:
ST
O T _______________________________
P ain: Location__feet__________________________ Rating__7____/10 Location__Right leg______________________ Rating_ 7_/10
N A – N o pain reported
A ble to follow : 1
2
P t is unsafe in the follow ing activ ities:
A mbulation (
Lev el S urfaces,
U nlev el S urfaces)
Transfers
W/C M obility
S tairs
O ther ___________________
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
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”
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
Where to Document PLOF –
Outpatient and HCC
• Outpatient/HCC Evaluation Certification
Form: Page 2, Space #20
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
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”
Skilled Intervention
Action Words
Where to document Skill Outpatient and HCC
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
Short-Term Goals
Progressed
Short Term Goals
• Smaller objective, functional goals that will be
progressed and revised throughout the POC to
achieve the LTG
Short-term Goals
Progressed (cont.)
• 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 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
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
Where to Document ShortTerm 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
Where to Document Short-Term
Goals in Outpatient/HCC
• Evaluation Certification Form: Page 2, #24
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
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.”
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
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
Patient’s Response / Progress
Example – Exercise Record
EXERCISE RECORD
PT
OT
ST
Patient's Name _____Susan Smith_________
Patient’s Tx Wk (ex: Tues – Mon or Fri to Thurs) Friday
____________________
to to ________________________
Thursday
Record reps, w eights, time, etc. to document progress and increased levels of difficulty.
Date
10/20/06
Date
10/23/06
Date 10/24/06
Date
10/25/06
Date
10/26/07
Exercise
Lingual lateralization
Lingual Resistance
x5 reps
2 seconds
x10 reps
2-3 seconds
x15 reps
5 seconds
x20 reps
5 seconds
x20 reps
10 seconds
• Note progress in repetitions, seconds, etc.
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!!
Innovative Senior Care
Rehabilitation…Fitness…Education