DOCUMENTATION AND SCALES

DOCUMENTATION AND SCALES

ROUTINE DOCUMENTATION Documentation should include: Clinical findings describing vital signs, weight loss/gain, fevers, wound status, etc Interventions provided and the response of the beneficiary and family. Teaching, communication and collaboration with facility and POA/Family. The course of the terminal illness. Interventions that are consistent with the plan of care.

1. ROUTINE VISIT DOCUMENTATION POOR DOCUMENTATION Diagnosis of dementia. Weight is 100 lbs. Poor appetite. Sleeps a lot. Has had past infections. GOOD DOCUMENTATION Hospice Diagnosis is Dementia, KPS: 40, FAST: 7D from 7A, PPS: 40%, Unable to make needs known and speech is nonsensical. Incontinent of bowel and bladder, cannot ambulate, and remains bed/chair bound. Weight loss of 15 lbs in the last 2 months, remains on honey thickened liquids and needs total assist with feeding and all other ADLS. Appetite is now poor. Three UTI s treated in last 6 months

2. ROUTINE SUPPORTIVE DOCUMENTATION ROUTINE VISIT Has poor appetite: eating 3-4 bites of food with difficulty as evidenced by pocketing of food. Eating an avg. of 25-50% of meals, drinks 2-3 sips of liquids coughing noted. Current weight of 100 lbs, weight loss of 15 lbs in 2 months. BMI 19.5 (May weight 115 lbs, June 106 lbs) April 2013 hospitalized for pneumonia and treated with IV Antibiotics.

ELEMENTS OF EFFECTIVE DOCUMENTATION Make sure spelling of all terms is accurate. When checking boxes, make certain they are accurate. Chart visit immediately if possible. Document the patient/caregiver/family s response to teaching and other interventions. Only use authorized abbreviations.

GENERAL DOCUMENTATION REQUIREMENTS Infections within the past 12 months. Details of medication(dosage, route, frequency), and the patients response. Refusals of treatment, medication, therapy, etc Document refusals to physician and all appropriate disciplines. Good to include repeating past observations that were evident of the patient s decline (i.e. recent hospitalizations, decreased tolerance to ADLs, etc).

GENERAL DOCUMENTATION REQUIREMENTS AS EVIDENCED BY ANYTIME ONE USES DESCRIPTORS SUCH AS: Cachectic, anorexic, non-ambulatory, dyspnea (at rest or on exertion), weight loss, poor appetite, fragile, agitated, weaker etc Always follow up with as evidenced by to fully describe what is seen: Example: Patient appears tachypnic as evidenced by respiratory rate of 32 and use of accessory muscles.

DOCUMENTATION FOCUS HOSPITAL Focus on what patient can achieve Curative treatment Documentation reflects a positive outcome HOSPICE Focus on what patient cannot achieve Palliative treatment Documentation reflects a negative outcome. SHIFT YOUR FOCUS FROM CURATIVE TO PALLIATIVE.

DOCUMENTATION REQUIREMENTS RN/LPN - CARE PLAN PROBLEMS Care plans need to be reviewed weekly. Related care plans should also be changed, updated and notes added when there is a change in the patient s condition. (For example when a patient is diagnosed with a UTI, the care plan should be updated with a note entered). When the issue has resolved the care plan should be resolved. Only care plans that should be open are ongoing issues.

DOCUMENTATION REQUIREMENTS RN/LPN - MEDICATIONS Medications need to be up to date and match the facility POS. Make sure to enter new medications and discontinue old medications at each visit. Entering Meds: Include: Dose, Route, Frequency and PURPOSE EXAMPLE: Albuterol 1 vial neb q 4hrs PRN for periodic SOB. What s it treating?

DOCUMENTATION REQUIREMENTS 24/48 hour admit follow up visits All pts need a 24-48 hour admit follow up done. Most are done by the next day. If a pts is admitted with pain, the admitting nurse will make note of this in the quality measure tab. On these pts there must be a 24 and 48 hour follow up visit. The 24 hour follow up visit is just a standard routine visit with clinical note. The 48 hour follow up is a routine visit, clinical note AND you must go into the quality measures tab and fill out the 48 hour assessment.

ROUTINE DOCUMENTATION REQUIREMENTS ROUTINE ASSESSMENT Record weights, infections, falls, etc Make sure to enter weights under clinical monitoring monthly. All infections and falls should be under their tab and end infections when they are no longer relevant. In each section throughout the assessment make sure you are clicking on appropriate boxes. If there is any change in pts baseline, there is a box in each section to elaborate on this.

ROUTINE DOCUMENTATION REQUIREMENTS ROUTINE ASSESSMENT SKIN Measurements must be done weekly by Hospice RN. Coordinate with the wound care nurse to be able to view the wounds Follow the wound care protocols.

VISIT FREQUENCIES Visit frequencies are to be determined by admission nurse. Visit frequencies: Aides-if they have a care giver or they don t need/benefit a spa/social visit, 3 aide visits a week may not be appropriate. Any visit frequency changes need to be discussed with RNC or DOCO. Make sure to update the visit frequencies in Allscripts and make sure the aide schedule reflects the correct amount.

COMFORT KITS Must be order upon admission, or at eval if necessary. Must be checked at 24 hours follow-up after admission. Must be checked weekly and documented in routine visit. Record expiration date in care plan, make sure you are ordering refill before med expires. If pt starts showing decline, or when medication is first used from comfort kit, refills should be ordered.

DOCUMENTATION OF SCALES Appropriate documentation of scales: PPS: Palliative Performance Scale. Pick the best fit option. To be a 30% the patient must require total assistance with ALL ADLs. The PPS scale is a measure of what the patient would be able to do, not on what they refuse to do. A patient that is able to feed self finger food, roll over in bed, or pivot with an assisted transfer would not be considered a PPS of 30%

DOCUMENTATION OF SCALES Appropriate documentation of scales: KPS: Karnofsky Performance Status Scale measures the patients functional impairments and can assess their prognosis. A KPS of 40 would be a total assistance with all ADLs. A patient living at home alone without a 24 hour care giver would not be a 40 or less. A KPS of 50 would be a patient that is unable to work but able to live at home and care for most personal needs with considerable assistance and frequent medical care.

DOCUMENTATION OF SCALES Appropriate documentation of scales: FAST: Functional Assessment Staging of Alzheimer s Disease. Can only be used if patient has a diagnosis of Dementia. A FAST score of 7C means the patient meets the criteria of ALL the previous stages. For example, a patient that has lost their ability to ambulate would ONLY be considered a 7C if they also were incontinent of bowel and bladder, Speech ability limited to the use of a single intelligible word and requires assistance with ADLS.

MISC Communication with team, working together with SW, Aide, RNC, Chaplain, etc. ADP, questions and review.

SOURCES BERRY, R. (2010). Understanding and Documenting the General Inpatient Care Level of Care [PowerPoint slides]. Retrieved from R&C Healthcare Solutions; http://www.rchealthcaresolutions.com/. Center for Medicaid Services - http://www.cms.gov CMS Benefit Policy Manual - http://www.cms.gov/manuals/downloads/bp102c1 5.pdf NHCPOhttp://www.nhpco.org/templates/1/homepage.cfm

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