Great article Holly!!!!!!!
Brenda W. Chance, RN, RAC-C
MDS Coordinator
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-----Original Message-----
From: Noelle Shough
[mailto:[EMAIL PROTECTED]
Sent: Tuesday, November 25, 2003
10:57 AM
To: '[EMAIL PROTECTED]'
Subject: RE: sentinel event
question . answer needed. 2 nd attempt
I thought I might post Holly's
article for you from the November PPS Alert. There's some great advice in
there from her. Enjoy!
Noelle Shough
Senior Managing Editor
HCPro, Inc.
(781) 639-1388 ext. 3138
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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 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.
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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-----Original
Message-----
From: Holly Sox, RN, RAC-C
[mailto:[EMAIL PROTECTED]
Sent: Tuesday, November 25, 2003
7:57 AM
To: [EMAIL PROTECTED]
Subject: Re: sentinel event
question . answer needed. 2 nd attempt
Sorry, Nancy, for not replying
sooner.
I would not code impaction based on
a nurse's note, just as I would not code a UTI or pneumonia simply based on a
nurse's note. In this case, I would write a progress note (we keep
MDS/Care plan progress notes with the care plan, but you could do a nurse's
note if that's your facility policy) stating that a nurse's note
indicated impaction, but that the KUB did not support that assessment, and that
the constipation was relieved by oral mag citrate. Then, do an inservice with
your nurses on what is required for the diagnosis of impaction.
I don't have the reference with me
for this, but we teach that impaction is hard stool identified on Xray or
digital exam that must be manually removed. If the patient/resident can clear
the rectum with oral laxatives , suppository or enema then it is not an
impaction.
See my PPS Alert article this month
about documentation. I have tried using an incentive approach.. when I find an
example of really good documentation, I award the Golden Pen to that nurse, and
praise him/her publicly.
----- Original Message -----
Sent: Monday,
November 24, 2003 5:37 PM
Subject: sentinel
event question . answer needed. 2 nd attempt
I have a resident admitted approc 11
days ago. She had a KUB done to confirm a right utereral stent placement.
Unfortunaley, the results read " severe constipation with dilatation of
the colon and copious stool in the rectum" Also, unfortunaely , a nurse
wrote in her nrsg notes fecal impaction per KUB results new order rec'd for mag
citrate. THis resident's adm obra assessment is due and this ? fecal impaction
falls with in the 14 day window. What would your code fecal impaction or not?
please help
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