Why focus on Documentation Competency?

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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

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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 isnt documented . . .
• it didnt happen!

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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

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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

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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

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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

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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

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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

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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

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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

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Essentials in Documentation

• Technical Completion/Accuracy
• Medical Necessity of Skilled Intervention

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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

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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

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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 900 A.M. following day)
OASIS Completion 4 calendar days from SOC N/A
Physician Signed Dated Evaluation Form Must have by End of Episode or prior to billing of claim Within 30 days from SOC 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
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Top 5 Focus Areas for Medical Necessity

• Medical and Treatment Diagnosis supported
• Prior Level of Function
• Skilled Intervention
• Goals Progressed
• Patients Response / Progress

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Diagnosis Supported

• Objective measures, tests, and assessments
• Medical History
• Medical Questionnaire
• Physicians Order includes diagnosis

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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

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Where to document Diagnosis - HCHB
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Where to Document Diagnosis Outpatient and HCC

• Evaluation Certification Form, Page 1, s 15-16

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Prior Level of Function

• Describes the patients 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

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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

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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
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Where to Document PLOF Outpatient and HCC

• Outpatient/HCC Evaluation Certification Form
  Page 2, Space 20

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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

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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

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Skilled Intervention Action Words

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Where to document Skill -Outpatient and HCC
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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 todays 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

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Short-Term Goals Progressed

• Short Term Goals
• Smaller objective, functional goals that will be
  progressed and revised throughout the POC to
  achieve the LTG

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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

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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

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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

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Where to Document Short-Term Goals in HCHB

• The NDPs (Nursing Diagnoses/Problem Statements)
  establish each disciplines 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 patients 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
  

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Where to Document Short-Term Goals in
Outpatient/HCC

• Evaluation Certification Form Page 2, 24

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Patients 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

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Patients 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.

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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

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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

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Patients Response / Progress Example Exercise
Record

• Note progress in repetitions, seconds, etc.

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Final Thoughts

• Good Documentation tells the
• patients story.
• In any care setting. . . we can demonstrate the
  value and necessity of our service by describing
  the patients 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!!

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Innovative Senior Care

• RehabilitationFitnessEducation