WHAT IS DOCUMENTATION?

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August Waters
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2 LEARNING OBJECTIVES: Describe documentation and its purpose in hospice Distinguish problematic documentation practices Recognize the relationship between documentation and the payment of claims Describe the importance of the Plan of Care Review examples of effective documentation

3 WHAT IS DOCUMENTATION? Material that provides official information or evidence or that serves as a record. The documents, records, etc., that are used to prove something or make something official Documentation is communication Documentation of care is synonymous with care itself

4 IMPORTANCE OF DOCUMENTATION Depicts patient-family specific goals Illustrates the medical necessity of palliative care interventions implemented Describe burden of end-stage illness/caregiving Identifies measurable end-stage disease progression Identifies outcomes and value of your care

5 DOCUMENTATION IS NOT Something I have to do that has nothing to do with the care of the patient and family Something to be done at 10pm at night after the kids are in bed Ever heard this? She s a really good nurse but her documentation is really poor.

6 WHY IS DOCUMENTATION IMPORTANT? Fundamental component of your practice accountability (assessment, professional practice, professional judgment, critical thinking) Good documentation compliance Establishes and supports eligibility for the Medicare Hospice Benefit Supports eligibility for the level of care Determines proper reimbursement Supports compliance with the Medicare CoPs, state licensure regulations and accreditation standards Good compliance supports good care

7 Data That Doesn t Fit Ill-Defined Data Missing Data Problematic Documentation One-Sided Data

8 MISSING DATA

9 MISSING DATA Missing data can cause documentation to be subject to interpretation

10 GATHERING THE DATA - ALL IDG MEMBERS History of present illness Past medical history Comorbid and Secondary Conditions Recent hospitalizations Drug profile Pertinent medical records Labs Imaging reports Patient and family story

11 GATHERING THE DATA - ALL IDG MEMBERS Goals of care Physical needs Psychosocial needs Emotional needs Spiritual needs Environmental factors Symptomology Imminence of death Complications and risk factors

12 DATA THAT DOESN T FIT

13 DATA THAT DOESN T FIT Inconsistent data can produce conflicting documentation which, in turn, undermines the reliability of the information.

14 COMMON INCONSISTENCIES Conflicting measurements: A documented mid-arm circumference of 22cm one week; 17cm the following week; and 22.5cm the next week without supporting data for the changes in measurement (e.g. weight fluctuations, edema)

15 INCONSISTENT DOCUMENTATION EXAMPLE 92 year old female with principal hospice diagnosis of Alzheimer s disease. Secondary conditions include dysphagia and coccygeal decubitus ulcer stage III. Resides in skilled nursing facility. Pt. lying in bed, 6/6 ADLs, nonsensical speech, head needs to be propped up with pillows, eating less, weight loss, sleeping more, must be fed by staff. FAST 7d. Wound care for stage III performed. Met with pt. in her room. Family not present. Pt. appeared comfortable, denied pain. Pt. shared photos and stories of her grandchildren. Appears thinner. Sleeping a lot.

16 ILL-DEFINED DATA

17 CAUTION! VAGUE WORDS AHEAD

Seldom Often Frequently Describe instead of judge.

18 Examples of Potentially Vague or Judgmental Words None Less Increased Decreased Better Worse Longer Seldom Often Frequently Describe instead of judge. Nothing is normal or expected. Be specific instead of vague.

19 ILL- DEFINED DOCUMENTATION EXAMPLE Pt lying in bed, 6/6 ADLs, nonsensical speech, head needs to be propped up with pillows, eating less, weight loss, sleeping more, must be fed by staff. FAST 7d. Wound care for stage III performed. Ill-defined pieces? Comparative words without comparisons Vague/judgmental words that need data to describe

20 ILL-DEFINED DOCUMENTATION EXAMPLE Pt lying in bed, 6/6 ADLs, nonsensical speech, head needs to be propped up with pillows, eating less, weight loss, sleeping more, must be fed by staff. FAST 7d. Wound care for stage III performed. How much dependence for these ADLs? Eating less than what/when? As evidenced by what? How much weight loss? As evidenced by what? Sleeping more than what/when? As evidenced by what?

21 ILL-DEFINED DOCUMENTATION EXAMPLE Pt lying in bed, 6/6 ADLs, nonsensical speech, head needs to be propped up with pillows, eating less, weight loss, sleeping more, must be fed by staff. FAST 7d. Wound care for stage III performed. What is meant by fed by staff? How much is consumed? Was there a wound assessment? What type of wound care was provided? How did the patient tolerate the wound care?

22 WELL-DEFINED DOCUMENTATION EXAMPLE Pt lying in bed. Bed bound, total dependence on caregivers for 6/6 ADLs, uses indwelling urinary catheter, incontinent of bowel and bladder, unable to reposition self, nonsensical speech, head needs to be propped up with pillows. Eating less as evidenced by now consuming only bites of food twice daily; 1 month ago was consuming 1/2 cup of pureed diet three times daily. Weight loss as evidenced by decrease in right MAC from 20cm 2 weeks ago to 18cm. Face gaunt, temporal wasting, ribcage protruding, required change from medium to small briefs last week

23 WELL-DEFINED DOCUMENTATION EXAMPLE Sleeping more as evidenced by now sleeping 23 hours/day, only wakes briefly during personal care and falls asleep after 1-2 bites of food, 1 month ago was able to remain awake to complete meal. Must be fed by staff, patient able to lift spoon to her mouth 1 month ago, now requires prompting and monitoring due to pocketing of food. FAST 7d. Wound care for stage III coccygeal decubitus ulcer performed per orders with SNF staff assistance. Pt no longer able to hold bedrail during dressing changes. Tolerated dressing change well, no nonverbal signs of pain noted.

24 ILL-DEFINED DOCUMENTATION EXAMPLE Met with pt in her room. Family not present. Pt appeared comfortable, denied pain. Pt shared photos and stories of her grandchildren. Appears thinner. Sleeping a lot. How did the patient present? Lying in bed? Up in chair? What is meant by appeared comfortable? As evidenced by what? What is meant by denied pain? Did the patient speak? Shake her head when asked?

25 ILL-DEFINED DOCUMENTATION EXAMPLE Met with pt in her room. Family not present. Pt appeared comfortable, denied pain. Pt shared photos and stories of her grandchildren. Appears thinner. Sleeping a lot. What is meant by shared photos and stories? Was the patient talking? If so, how much? What is meant by appears thinner? What is meant by sleeping a lot?

26 WELL-DEFINED DOCUMENTATION EXAMPLE Met with pt in her room. Pt lying in bed asleep upon arrival, awoke to gentle and light touch. Family not present. Pt appeared comfortable as evidenced by no noted non-verbal signs and symptoms of pain, smiled intermittently. Denied pain. Pt shared photos and stories of her grandchildren. Read to pt stories about her grandchildren from a book patient had written about her life. Sleeping a lot as evidenced by waking for brief moments lasting less than 1-2 minutes intermittently during visit. 1 month ago pt remained awake for full duration of visit.

27 ONE-SIDED DATA

28 Tell me what you see?

29 ONE-SIDED PERSPECTIVE PITFALL In order to depict an accurate reflection of the patient s hospice eligibility, the whole clinical picture, how the patient and family are experiencing this time and responding to your care should be evidenced in the documentation. Physical Functional Interpersonal Well-being Spiritual

30 MR. MARKS This is a 76 year old male with principal hospice diagnosis of chronic obstructive pulmonary disease (COPD). He had been on service for 8 months and has been showing evidence of significant disease progression in recent weeks. He now requires the administration of supplemental oxygen administered at 3 liters per minute (lmp) via nasal cannula continuously, an increase from 2 lmp 1 month ago, and uses nebulizer treatments routinely throughout the day for shortness of breath. Last week, his dosage of short-acting morphine was increased from 5mg every hour as needed for shortness of breath due

31 MR. MARKS to increased dyspnea with minimal exertion. A long-acting dose of morphine, which he now takes every 12 hours daily, was also added to his medication regimen to palliate his worsening baseline dyspnea. He resides in his home with his wife, who serves as the primary caregiver. His goals include no further hospitalizations and to remain comfortable in his home without a lot of fuss ; he spent his favorite years living in Hawaii and hopes to be able to enjoy the outdoors and the sun as much as possible until he moves along to his next destination. His primary RN, making the scheduled weekly visit, creates the following documentation.

32 ONE-SIDED DATA EXAMPLE Upon arrival to the home, pt sitting out on his porch enjoying the sun. Pt wearing O2 at 3 lpm via NC, denies SOB. Lung sounds diminished all lobes, some expiratory wheezing BUL. Pt talked about his days living in Hawaii and how much he loved watching the big-wave surfers. No needs at this time. Pt well palliated. Refill of dulcolax ordered. How did this happen? Ask the question to find out Burden of illness Burden of caregiving

33 THE OTHER SIDE OF THE BIGGER PICTURE Upon arrival to the home, pt sitting out on his porch enjoying the sun. Pt wearing O2 at 3 lpm via NC, denies SOB. Pt reports that he took morphine 10mg 1 hr prior to visit due to anticipated SOB with exertion of ambulating. Pt reports that 30 minutes prior to visit, he ambulated from his recliner to the porch where he prefers to have visits, a distance of 15 feet which took him 5 minutes. He needed to stop multiple times d/t SOB and to catch his breath while holding on to walls for support. Lung sounds diminished all lobes, some expiratory wheezing BUL. Pt reports that it took him 20 minutes to recover following his ambulation from recliner to porch, during which time he used his nebulizer tx for SOB. Spouse reports pt was pursed lip breathing and needing to sit in tripod position during that time and his lips were blue

34 THE OTHER SIDE OF THE BIGGER PICTURE Pt took another dose of morphine 10mg immediately prior to this nurse s arrival. Pt talked about his days living in Hawaii and how much he loved watching the big-wave surfers. Pt needed to pause when speaking more than 2-3 sentences in order to catch his breath. RR increased from 20 to 34 after speaking for 1 minutes. No needs at this time. Pt well palliated with current plan of care including recent increases in dosage of prn morphine and supplemental oxygen, and the addition of MS Contin to his daily regimen. Pt reports increased usage of dulcolax d/t constipation r/t increased morphine usage. Refill of dulcolax ordered.

35 THE BIGGER PICTURE

36 PLAN OF CARE According to CMS (Centers for Medicare and Medicaid Services) the Plan of Care is one of the most important process/document in hospice care.

37 PLAN OF CARE CMS identified Plan of Care as one of the top deficiencies in There are 2 specific Conditions of Participation Standards where deficiencies were found.

38 418.56(B) STANDARD: PLAN OF CARE All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient s needs if any of them so desire. (#2 deficiency in 2015, #1 in 2014 and #1 in 2013)

39 418.56(C) STANDARD: CONTENT OF THE PLAN OF CARE The hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. (#4 deficiency in 2015, #2 in 2014, #2 in 2013)

40 EXAMPLES OF FINDINGS: Plan of care not individualized (i.e. the chaplain frequencies are the same for all patients regardless of patient status). Missing or incomplete documentation Inadequate or lack of IDG collaboration Collaboration of plan of care goals with the patient/representative not documented Physician orders missing

41 EXAMPLES OF FINDINGS: RN removed a patient s Foley catheter based on his wife s request, as she would rather change him and husband would find more comfortable, but care plan a month later reflected catheter care and goals related to patient having a catheter. With some frequency plans of care indicated care wound care, oxygen, or Foley care per standing orders but no standing orders were present in chart. Failure to have proper information in plan of care relative to wound care, either information was missing or not accurate, was also a frequent survey issue. IDT provided services not found on the POC.

42 COMPLIANCE RECOMMENDATIONS: Ensure POC is individualized. As the patient changes, so should the POC. If the patient is declining, are visit frequencies/interventions increasing? Match problems and interventions in assessment and POC. Ensure that the POC integrates changes based on assessment updates and findings. Discuss POC with patient/family. Be sure to address GOALS and document these conversations. Document all communication about coordination of care.

43 HOW DO YOU KNOW? Anytime you use a description like: Cachectic, anorexic, non-ambulatory, dyspnea (at rest or on exertion), weight loss, poor appetite, fragile, failing, weaker Always follow up with as evidenced by (AEB) to fully describe what you see

44 DOCUMENTATION: The masterpiece that portrays our quality of care

45 WHAT DOES YOUR MASTERPIECE LOOK LIKE?

What do we promise people who are dying and those around them when we tell them about hospice care?

What do we promise people who are dying and those around them when we tell them about hospice care? Care Planning The Road to Meeting Patients and Families Where They Are Charlene Ross, MBA, MSN, RN Consultant/Educator R&C Healthcare Solutions & Hospice Fundamentals 602-740-0783 charlene@rchealthcaresolutions.com