Monday, October 12, 2009

Hospice Documentation

The clinical director sends us copies of Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional each month. The October issue had an interesting article regarding hospice documentation, specifically related to performance improvement and CoPs (Conditions of Participation.) If you or your organization subscribe to the journal, it's well worth reading. Assuming you don't have access to the article, I'll leave you with some of the highlights.

CMS started collecting data in 2007 and will launch phase 3 on January 1, 2010. Hospice providers will then be required to list visit lengths and number of visits by physicians/nurse practitioners, nurses, social workers, and aides, as well as PT, OT, and ST, and the length of phone calls made by social workers that are related to the terminal illness. It is well worth noting that complete comprehensive documentation by the interdisciplinary group (IDG) members is even more critical now that so many governmental systems are watching hospice providers. Documentation provides evidence of the care provided, verifies the quality and coordination of care, ensures continuity of care, shows compliance with various regulations and organizations, provides substantiation of the sequence of care in the court of law, and provides the basis for service reimbursement. (Ah, yes, it always comes back to money.)

Documentation should tell the patient's story in a legible, complete, and consistent way. The story begins with the initial assessment of the patient's needs, as well as the needs of the family or caregiver. IDG members should consistently and objectively document the patient's and family's/caregiver's status and the state of their environment each contact. There should be 1) a complete description of interventions provided to the patient and family or caregiver, 2) the patient's pain and symptom presentation and interventions and evaluations, 3) communication with the MD, other IDG members, and any nonhospice professionals, and 4) the observed or verbal responses to interventions and care.

Stay away from vague, inconsistent, and contradictory statements about the patient's status or clinical interventions. Avoid using these: "continues slow decline," "remains hospice appropriate," and "needs more care." Make sure the hospice team is seeing the same thing, i.e. the RN documents that the patient is ambulatory while the aide lists the patient as bedbound.

Comparative charting is a best practice method. Comparative charting contrasts the patient's present condition to their prior condition. This also individualizes the patient by looking at their specific trajectory of decline and presenting specific information instead of generalizations. Assessment of the terminal condition should be emphasized and also include any comorbidities that impact the prognosis. There should also be an individualized description of the patient's status as it relates to the terminal diagnosis. Examples can include documenting any limits to daily activities for a patient with CHF or describing the use of oxygen for a patient with COPD.

My organization is currently examining how we document and trying to streamline the process. Social workers and chaplains started using Assessment-Intervention-Plan as a guideline for our clinical notes. It was an adjustment at first to figure out how to structure the clinical note, since I was used to a free form narrative. However, now that I've been doing it for about 2 months, I love it! Each visit, I copy the old note in to the new one and tailor it to the visit I just made. It serves as a refresher for what I've been working on with that patient and helps me keep my plan of care more current. I don't know what Medicare will throw at us next but I think my organization is ready to meet the challenge.

1 comment:

Anonymous said...

My name is Kathy and I am the full time caregiver for my eighty one year-old Dad who has Alzheimer's and lives with me in North Carolina.

When my Mom died in 2004 and Dad moved in with me, I had no idea what to do. But day by day, I found ways to cope, and even enjoy having my Dad with me.

So I started writing a blog at www.KnowItAlz.com, which shows the "lighter" side of caring for someone with dementia.

After a while, I added over 100 pages of helpful information and tips for caregivers. We even have a Chat room so caregivers can communicate with each other from home. Art and music are a very large part of my Dad's therapy.

Please pass this link along to anyone you feel would enjoy it.

Thanks!
Kathy Hatfield