Day 3: Documentation, Documentation, Documentation
Documentation, Documentation, Documentation
Tell the Story
Be able to tell a good clear story from Admission to Discharge of the patient’s condition and journey through your agency.
Comprehensive home health documentation is vital to ensuring both quality patient care and proper reimbursement.
Stronger focus on investigating what CMS deems as fraudulent activity combined with efforts to ensure more accurate reimbursement means that home health agencies must take steps to ensure documentation integrity.
Tell the Story
- Clinical documentation should begin with a complete assessment and evaluation of the patient. Clinicians must record all details of their evaluation, clearly establishing he patient’s condition upon start of treatment. This is the benchmark for tracking treatment progress.
- Each clinician must develop a thorough plan of care delineating a clinical route for getting the patient from their starting point to a higher level of health and functionality.
- Plans of care should include goals, treatment types and specific measures for outcome.
- Progress notes should clearly denote the care rendered and how it relates to the patient’s plan of care.
- Treatment notes should indicate the impact of the intervention or treatment on the patient’s overall condition.
- Charting needs to be clear, specific, and measurable.
Home health agency progress notes become part of the patient’s medical record. Overall, the primary goal of proper clinical documentation is to ensure the quality and continuity of care to the patient by allowing the next care provider to know what you did, why you did it, and the benefit to the patient. Appropriate documentation promotes:
- a high standard of clinical care
- continuity of care
- improved communication and dissemination of information between and across service providers
- an accurate contemporaneous account of treatment, intervention and care planning
- improved goal setting and evaluation of care outcomes
- improved early detection of problems and changes in health status
- evidence of patient care
Good clinical documentation protects your agency
The patient is what you document! Your documentation shows the quality of care you give your patients. It protects you from malpractice and minimizes your risk of takebacks and/or audits. Additionally, well organized documentation makes it easier for surveyors to review your care practices and find the information they are looking for quickly and easily. How does Medicare know if you are doing what you are being paid for? Through your documentation!
Your documentation should include:
- Individualized care plan
- Assessments and the patient’s clinical status
- Functional Goals
- Interventions and the patient’s response
- Variances from expected outcomes (medications, procedures, protocols) and the action taken
- Communication with physicians and others
- All unusual patient occurrences or incidents
- All patient adverse events
Paint the Picture
Recognizing that every patient’s medical story is unique, and ensuring that documentation is specific to him or her is vital to warranting that every patient receives the quality of care they needs.
The goal of documentation is comprehensive care with the very best possible outcomes, and consistent clinical documentation that ensures compliance and protects home health agencies.
Medical Record is a Legal Record
- Missing, Incomplete, or Incorrect Documentation
- Documentation that doesn’t clearly and accurately convey a patient’s care plan can lead to a lot of issues for a home health agency, including reduced reimbursement, increased risk of audits or takebacks, patient safety issues, inadequate care coordination, and more.
Medically Reasonable & Necessary
- Services address the written reasonable goals.
- Services are necessary for the patient’s written diagnoses & assessed needs.
- Every visit is necessary to meet the patient’s goals.
- Is there any progression noted?
When documenting medical necessity, your clinical notes should include the following for every discipline: Assessment specific to the day of each visit; skilled services performed at each visit – if nothing skilled is done, the visit may not be paid; patient’s response to treatment rendered; plan for the next visit — if there is no plan, is a next visit necessary?
Remember, home health is not intended to be a lifelong event.
Helpful Charting Tips
- If your company uses pre-printed forms or a checklist format be sure to complete forms accurately. If you need more space to include a narrative, add a sheet.
- Use “just the facts” approach, avoid adverbs, opinions, or adjectives. This may be helpful to you or your employer if there are allegations of wrongdoing.
- If you need to make changes to the documentation do not “cross out” or “white out” the error. Rather, initial it and add the correction to the record. If you need to add something later (on a different date) it is best to enter a separate “late entry” explaining it is a late entry (not necessarily why) and initial the same. Changes or additions should be minimized as they can lead to confusing records and perceptions of poor care and decision making practices.
- Make progress/chart notes the same day as services are rendered. Chronological entries generally are considered more reliable as a representation of care rendered.
- Do not forget to include date, name, professional designation, and initials to documentation entries.
- When charting patient’s progress, focus on his needs and plan to treat unresolved problems.
- Documentation must be patient focused and based on professional observation and assessment that does not have any basis in unfounded conclusions or personal judgments.
- Identify the source of information (including information provided by another health care professional or patient family member)
- Document each time you teach the patient, family, and/or caregivers.
- It should be assumed that any and all clinical documentation will be scrutinized at some point.
- Detailed documentation in relation to critical incidents such as patient falls, harm to patients, or medication errors.
- Don’t be vague, Be specific
484.48 Condition of participation: Clinical records
A clinical record containing pertinent past and current findings in accordance with accepted professional standards is maintained for every patient receiving home health services. In addition to the plan of care, the record contains appropriate identifying information; name of physician; drug, dietary, treatment, and activity orders; signed and dated clinical and progress notes; copies of summary reports sent to the attending physician; and a discharge summary.
The HHA must inform the attending physician of the availability of a discharge summary. The discharge summary must be sent to the attending physician upon request and must include the patient’s medical and health status at discharge.
- Standards: Retention of records. Clinical records are retained for 5 years after the month the cost report to which the records apply is filed with the intermediary, unless State law stipulates a longer period of time. Policies provide for retention even if the HHA discontinues operations. If a patient is transferred to another health facility, a copy of the record or abstract is sent with the patient.
- Standards: Protection of records. Clinical record information is safe-guarded against loss or unauthorized use. Written procedures govern use and removal of records and the conditions for release of information. Patient’s written consent is required for release of information not authorized by law.
- Clinical documentation is written not just for a clinician to remember a patient’s case or to share information with another clinician working on a patient, but also for Medicare or another insurance reviewer to understand the necessity and progression of the patient’s course of treatment.
- Medicare pays for a patient’s progress or at a minimum, maintenance. As care providers render services they should clearly denote (1) the care provided, (2) how that care relates to the patient’s plan of care, and (3) the impact of the care or treatment on the patient’s overall condition.
- Charting needs to be specific and measurable and contain significant detail to best ensure insurance/Medicare reimbursement.
Detailed documentation will better ensure Medicare will not deny payment due to “lack of medical necessity”, when the problem is really lack of documented medical necessity.