Try a cheat sheet for better
Medicare documentation in your nursing home
Getting appropriate documentation to support your residents' needs
for skilled services can be tricky at times-especially when staff aren't
quite sure what a resident's main reason for coverage is. However in this
era of extra scrutiny by fiscal intermediaries (FIs) and government
agencies of Medicare claims, it's critical to cover all your bases in the
field of documentation.
That's why Holly Sox, RN, BSN,
RAC-C, MDS manager at J.F. Hawkins Nursing Home in Newberry, SC, uses
a Medicare documentation cheat sheet to ease nursing staff's burden
concerning adequate documentation to support claims for services covered
under PPS.
"The cheat sheet lists the primary reason the resident
is skilled for Medicare, specific things that the daily [nurses'] notes
should include, and a primer on the late-loss activities of daily living
[ADLs]," says Sox. Whether a resident receives skilled services mainly for
rehabilitation, wound management, infection care, or other treatment
issues, nurses can access the cheat sheet from the resident's chart and
know what kind of documentation is necessary.
A comprehensive progress note
Sox, who was recently elected Nurse Assessment Coordinator of the
year by the American Association of Nurse Assessment Coordinators, keeps
documentation for the MDS on track by requiring daily progress notes for
Medicare residents.
"In this facility, we require for everyone on
Medicare a comprehensive progress note that addresses the reason they're
skilled and what's going on that day," she explains. Certified nursing
assistants will document basic care and residents' vital signs, while the
nurse on the floor might record more complex care administered to the
resident. By following Sox's cheat sheet, nursing staff can address all
pertinent areas in their documentation.
If a resident falls into
one of the lower 18 Resource Utilization Groups (RUGs), however, Sox will
complete the daily progress note herself. "I'll do it because I know what
I'm looking for," she explains. Claims for residents in the nonrehab
categories tend to draw more scrutiny from FIs, so it's best to have
documentation to back up these services.
Generally, a resident who
is in one of the lower 18 RUGs requires care for behavior problems, she
says. "I'll describe why [the resident] needs one-on-one
supervision."
The A to Z of ADLs
The cheat sheet includes a primer on late-loss ADLs for a reason,
says Sox-because it can be difficult to get staff to understand the
nuances of ADL coding. "But the ADL index affects the RUGs so much, you
can't afford to have staff misunderstand the coding definitions," she
adds.
Although the facility incorporates a patient care record into
the charting, it doesn't specify the exact amount of assistance a resident
needs to perform any one of the late-loss tasks-bed mobility, transfer,
eating, or toilet use-so its worth is limited. Sox says she relies on
interviewing staff and reviewing the nurses' notes when coding Section G
of the MDS.
Staff still struggle with how to code late-loss
ADLs-specifically in the area of bed mobility. Staff may observe the
resident turning over unassisted and record "independent" in the notes-but
the resident can't go from sitting up to lying down alone, an important
part of bed mobility. "I find myself having to do a lot of education," Sox
says.
Section E isn't easy
Besides late-loss ADLs, Sox says she has to help staff with charting
in the area of mood and behavior patterns, which is Section E on the MDS.
It's not that staff don't understand the definitions of the items, but
rather that they don't always respond to residents' behaviors, she
explains.
"Many times they get used to a resident being that way
[i.e., tearful, angry, withdrawn] so they don't even document it anymore,"
she says. For instance, a resident may use abusive language to staff on a
regular basis. After a spell, staff may stop documenting that behavior
because the resident "always behaves in that manner."
"But you have
to document it, otherwise how do you know whether there's a change?" she
points out. Further, indicators of depression and behavioral symptoms can
have an impact on your RUG category, so by missing symptoms of problems,
you could be losing reimbursement on top of not providing the best care to
the resident.
Encouraging good charting
Any MDS coordinator worth his or her salt is aware of the importance
of appropriate documentation to back up claims for skilled services. But
how can you prompt staff to give you the notes you need?
Here are a
few ideas from Holly Sox, RN, BSN, RAC-C, MDS manager at J.F.
Hawkins Nursing Home in Newberry, SC, to get the best results from nursing
staff when it comes to Medicare documentation:
The golden pen award. People tend to respond well to positive
reinforcement, so Sox took this theory and incorporated it into what she
wanted to see for Medicare documentation. If a nursing staff member wrote
a note that covered exactly what she needed, she would praise that person
to the rest of the staff and pass the note around.
Sox even had metallic colored pens to hand out to the staff that
provided the best documentation, deeming those people winners of the
"golden pen award." "People respond so much better [to that] than repeated
inservices," she points out.
Feeling empowered. Many MDS coordinators who ever received
assessment information from a certified nursing assistant (CNA) flowsheet
likely worried about "copycat charting." CNAs who did not understand the
importance of accurate charting sometimes just copied exactly what the
person before them wrote-leading to highly inaccurate results.
However, Sox tried a different tactic at the facility she worked
for previously. "When we inserviced the CNAs and implemented the form, I
focused on their empowerment, that they took ownership of caring for the
resident-and that their individual knowledge of the resident was so
important to good care." CNAs responded positively to the challenge and
the flowsheets worked well in the facility, with minimal
copying.
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