Documentation Strategies for Nurses and Therapists January 2, 2007 at 1:00 EST

1. Documentation Strategies for Nurses and TherapistsJanuary 2, 2007 at 1:00 EST Lisa Bazemore, MBA, MS, CCC-SLP

2. Setting the Stage • Why do we document care? • To insure payment for the services rendered • To insure continuity of care • Principles of documentation: • Document to your audience • Focus on deficits • Attainable goals • Progress towards goals • Consider barriers to discharge • Consider return to both home and community

3. Setting the Stage • What is Medical Necessity? • A course of treatment that is seen as most helpful for the specific health symptoms that the patient is experiencing. This course of treatment is determined by the patient and their healthcare team.

4. Setting the Stage • 7 Criteria of Medical Necessity • Medical Supervision • 24 Hour Rehab Nursing • Relatively Intense Level of Services • Multidisciplinary Approach • Coordinated Care Plan • Significant Practical Improvement • Realistic Goals

5. Components of Medical Necessity • Close Medical Supervision • 24 hour availability of a physician • Entries in the chart every 2 -3 days minimum • Greater involvement that in other settings

6. Components of Medical Necessity • 24 Hour Rehabilitation Nursing • Need availability of an RN with rehab experience around the clock • Have clear, functional rehabilitation goals • Nursing is involved in the overall plan of care, not just medical issues and bowel and bladder management • Nursing documentation supports FIM scores • Nursing documentation clearly identifies how they facilitate the carryover of learning from therapy sessions • Nursing documentation supports the medical management of the patient

7. Components of Medical Necessity • Relatively Intense Level of Rehabilitation Services • The 3 Hour Rule • Minimum of 3 hours of therapy, 5 days per week • Therapy is at a skilled level • Must be necessary for meeting the basic needs of the patient’s health • Must be consistent in type, frequency, and duration • Consistent with the patient’s diagnosis

8. Components of Medical Necessity • Interdisciplinary Approach • Members work collaboratively to develop goals and the treatment plan • Team members engage and learn from each other • Collaborative ownership of the patient treatment plan

9. Components of Medical Necessity • Coordinated Plan of Care • Records need to show a treatment plan that is: • Derived from team assessment and patient expectations • Identifies STG’s and LTG’s • Defines how disciplines share responsibility • Supports need for intensive rehab services • Weekly team conference

10. Components of Medical Necessity • Significant Practical Improvement • We do not expect 100% independence for all rehab patients • We do expect reasonable, practical improvement • Improvement must be the result of skilled services provided • Important that it is documented clearly

11. Components of Medical Necessity • Realistic Goals • Aim of treatment needs to be achieving the maximum level of function possible

12. How Do We Document Medical Necessity? • Team has an ongoing opportunity to document medical necessity. This is achieved by documenting: • That services needed are of a complex nature that they require a licensed clinician • Services need to be in an inpatient setting • Services are consistent with diagnosis, need, and medical condition • Services are consistent with the treatment plan • Services are reasonable and necessary • Patient is making progress towards reasonable goals

13. Where Do We Document Medical Necessity? • Pre-admission Screening • Team Admission Assessments • Nursing Admission Assessments • Patient Care Plan • Long term goals • Short term goals • Identification of involved disciplines • Weekly progress notes • Discharge summaries • Team Conference Summaries

14. Diagnoses Comorbidities Age Current interventions Functional Assessment Vitals Safety History Meds Pre-morbid status/function Recommendation of need for 3 therapies Recommendation of need for 2 disciplines Rehab potential Areas where improvement is expected Preadmission Screening

15. Preadmission Screening

16. Prior level of function Required assistance Living situation Anticipated D/C plans Patients rehab expectation Individual FIM’s with emphasis on findings ROM and Strength limits Sensation, tone, etc. Community reintegration Pain assessments Summaries of findings Team Admission Assessment

17. Poor Team Admission Example

18. Why This Is Poor • No indication that skilled intervention is needed • All items were not assessed • No safety needs identified • Findings do not provide justification for skilled therapy • No indication of why FIM was 5 • No indication that intervention was needed on an inpatient basis • No indication that an interdisciplinary team is needed

19. Poor Team Admission Example

20. Why This Is Poor • Toileting was not assessed – this is an important area for assessment to establish the medical necessity for OT

21. Poor Team Admission Example

22. Why This Is Poor • SW does not indicate need for skilled social services • SLP does not link need for therapy w/return home potential • PT does not show need for skilled therapy services • No indication that 24 hour setting for intervention is needed

23. Improved Example of Team Assessment

24. Why This Is Improved • Need for interdisciplinary team clearly identified • FIM score supported • Indication that intervention is needed across the day • Supports need for skilled OT and ST

25. Improved Example of Team Assessment

26. Why This Is Improved • Supports impact of morbid obesity (comorbidity on treatment) • Supports need for interdisciplinary team • Supports need for skilled OT and PT

27. Improved Example of Team Assessment

28. Why This Is Improved • All disciplines document need for skilled level of intervention • Supports need for interdisciplinary intervention • OT’s identification of the need for toileting and bathing indicate the need for equipment that is not usually in OP clinics for patient training (bathtubs, commodes) • Rehab nursing clearly documents their role in the POC.

29. Documenting on the Patient Care Plan • The Patient Care Plan should include: • Prioritized patient goals • Impairments, Activity, Participation • Planned Discharge Site • Interdisciplinary Long Term Goals • What disciplines will be involved in the care of the patient • Interventions

30. IAP Example

31. Documenting Progress • At least weekly, a summary of the patient’s progress should be documented. • Document progress toward goals • Detail barriers to achievement of goals • Describe changes to the plan of care as appropriate • Describe patient’s response to treatment • State the justification for continued stay on the rehab unit

32. Poor Documentation of Progress

33. Why This Is Poor • Note does not reflect skilled intervention • Note does not address the reasons that skilled services are needed – the teaching of hip precautions, the teaching of adaptive equipment usage • Note does not document the need for continued skilled therapy

34. Improved Example of Progress

35. Why This Is Improved • Details the skilled intervention provided by the therapist – i.e., “taught”, “educated” • Addresses weekly short term functional goals • Summarizes daily treatment interventions • Documents need for continued skilled intervention

36. Daily Documentation of Medical Necessity • Daily documentation should show skilled need in: • Weekly short term goals • Total units of therapy • Treatment/training • Daily comments

37. Poor Documentation of Goals

38. Why Is This Poor • Typical pt. w/hip replacement would not need skilled therapy to relearn basic ADLs

39. Improved Example of Goals

40. Why This Is Improved • Details the need for OT in ADLS • Documents specific area requiring learning – it is not that patient needs to relearn how to put on clothes, bathe, etc., but that patient needs to learn how to use his hip precautions in each of these basic life activities • Puts ADLs into functional routine that has a meaningful measure to patient and family

41. What Constitutes a Skilled Service • Knowledge and training of a professional is necessary • Need should be indicated in initial evaluation • Evidence that skilled services were performed should be reflected in notes

42. What Constitutes a Skilled Service • Services must be of such a level of complexity and sophistication or the condition of the patient must be such that the services required can only be safely and effectively performed by qualified nurses and therapists. • Skilled services can be: • Diagnostic and assessment • Designing treatment • Establishment of compensatory skills • Providing patient instruction • Reevaluations

43. Skilled versus Non-Skilled

44. Denials • Why do payers tell us they deny claims? • Patient does not meet eligibility criteria • Services are not skilled • Services are not necessary for patient’s diagnosis, medical condition, or no assessed need

45. Denials • How can we avoid denials? • Document interventions clearly and precisely • Use active, descriptive verbs

46. Terms

47. Questions?Next call - February 6 at 1:00 EST Lisa Bazemore, MBA, MS, CCC-SLP Lbazemore@erehabdata.com (202) 588-1766