Nursing Documentation: Do Your Medical Records Support Skilled Care?

Nursing Documentation:
Do Your Medical Records Support
Skilled Care?
HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare International, Inc. (HHI)
Presented by:
Beckie Dow, RN, RAC-MT
Director of MDS / Nursing Education & Training

Director of MDS/Nursing Education &
Training for Harmony Healthcare,
International, Inc.
Over 20 Years Experience in Long-Term Care
Clinical and Reimbursement Accuracy in
Assessments
Quality Assurance Activities
Interrelation between MDS, Care Planning,
QA, and Clinical Excellence at the Bedside
AANAC Master Teacher
Speaker Bio (Beckie Dow)
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2

Harmony Healthcare International, Inc. 3
Do Your Medical Records Support Skilled Care?
Disclosure: The planners and presenters of this education
activity have no relationship with commercial entities or
conflicts of interest to disclose
Planners:
Elisa Bovee, MS, OTR/L
Diane Buckley, BSN, RN, RAC-CT
Keri Hart, MS CCC, SLP, RAC-CT
Kristen Mastrangelo, OTR/L, MBA, NHA
Christine Twombly, RNC, RAC-MT, LHRM
Presenter: Beckie Dow, RN, RAC-MT
Copyright © 2013 All Rights Reserved

Harmony Healthcare International, Inc.
Disclosure
Speaker:
The speaker has no relevant financial
relationships to disclose
The speaker has no relevant nonfinancial
relationships to disclose
Copyright © 2013 All Rights Reserved 4

Criteria for Successful Completion
Complete Sign-in and Sign-Out on
Attendance Form
Attendance for entire session
Completion and submission of
speaker evaluation form

Harmony Healthcare International, Inc. 6
Program Objectives
The learner will be able to describe the technical and
clinical requirements for Medicare coverage
The learner will be able to state the goal of
supportive skilled nursing documentation
The learner will be able to identify sections for the
MDS 3.0 assessment that are vulnerable to error and
articulate strategies to support these areas in medical
record documentation
The learner will be able to identify the correlation
between medical record documentation, the MDS 3.0,
and publicly reported information for the Quality
Measures and 5 Star Quality rating
Copyright © 2013 All Rights Reserved

Program Goals
This program will enable Healthcare
providers to provide quality healthcare
through understanding the
requirements of skilled Medicare
documentation and provide examples
of skilled nursing documentation that
will support a skilled level of care.

What is Medicare?
Medicare is a federal health insurance program for people 65 or
older and certain disabled people
It is administered at the federal level by the Centers for
Medicare and Medicaid Services (CMS)
Two parts--Hospital insurance and medical insurance
Medicare payments are handled by private insurance
organizations under contract with the Government
Organizations handling claims from hospitals, SNFs, and HHAs
are called intermediaries
Organizations handling claims from doctors, supplies for SNFs
and other suppliers of services covered under the medical
insurance part of Medicare are called carriers

Medicare Coverage
In each benefit period Medicare Part A
pays for all covered services in the first
20 days in the SNF.
Daily co-insurance amount is assessed
to the beneficiary from 21st to 100th day
Medicare only covers skilled care
Medicare does not cover custodial care

Medicare Part A Coverage
Requirements

Technical Requirements
Technical requirements are not eligible for
appeal—if the patient does not meet technical
requirements their stay will not be covered
It is the responsibility of the facility to
determine if technical eligibility requirements
are met
Best practice: The facility should have a
process for determining technical eligibility
prior to admission

Beneficiary is enrolled in Medicare Part
A and has available days
Beneficiary had a three-day qualifying
hospital stay
Skilled care must begin within 30 days
after discharge from a hospital or the
last covered Medicare day of a SNF stay

Three-day qualifying stay does not
include nights spent in observation
status or in an ER bed
Can be in different hospitals, but nights
must be consecutive
The day of admission, but not the day
of discharge, is counted in the three
days

Skilled care must begin within 30 days
(unless the Medical Appropriateness
Exception applies)
Medical Appropriateness Exception-
Physician determines that an immediate
skilled stay would not be appropriate
for the patient
Skilled stay can be deferred longer than
30 days after hospitalization

Clinical (Level of Care)
Requirements
The patient requires physician-ordered
skilled nursing or rehabilitation services
that relate to the hospital stay or a
condition that arose while receiving post-
hospital care
The services are daily
As a practical matter, the services must be
delivered in the SNF
The services are reasonable and necessary
for treatment of the illness/injury

Medicare Coverage/Skilled Care
Provided on a “daily” basis:
Rehabilitation (PT, OT and/or SLP) must
be at least five days per week
An isolated break of “a day or two” is
allowable
Skilled nursing (or combination of
nursing and rehabilitation) must be seven
days per week
Restorative nursing Programs must be at
least six days per week

What is Skilled Care?
Nature of service requires the skills of a
licensed person (e.g. technical or
professional personnel)
Skilled services are provided directly by or
under general supervision of a licensed
nurse or therapist to assure the safety of the
patient and to achieve the medically desired
result
Diagnosis and prognosis do not determine
what is skilled care – it is the care of the
patient that is the deciding factor

“Practical Matter” Criterion
“As a practical matter,
considering economy and
efficiency, the daily skilled
services can only be provided
in a skilled nursing facility”

1. Outpatient services are not available in
the area where the individual lives.
2.Outpatient services are available in the
area where the individual lives, but
transportation to the closest facility
could cause an excessive physical
hardship, be less economical, or less
effective that placement in the skilled
nursing facility.

3. The availability at home of a capable and
willing caregiver should be considered, but the
care can be furnished only in the skilled
nursing facility if home care would be
ineffective because there would be insufficient
assistance at home for the patient/patient to
reside there safely.
4. If the use of alternative services would
adversely affect the patient’s medical
condition, then as a practical matter the daily
skilled service(s) can only be provided on an
inpatient basis.

SNF Level of Care Criteria
Leave of Absence
“An SNF should not interpret the
practical matter criteria so strictly that
it results in the automatic denial of
coverage for patients who have been
meeting all of the SNF level of care
requirements but who have occasion to
be away from the SNF for a brief period
of time.”

Skilled Nursing
Documentation
Requirements

Basics of Documentation
Medicare has no specific requirements
related to documentation
Daily skilled care is required and must be
proven in the record
Documentation should be precise and contain
information supporting the skilled care
given
No specific format is required by Medicare

The person reading your note was likely not
present during your observations; you need
to paint a picture with your words for them
Written entries must be in terms easily
understood by anyone reading the notes
Documenting occurrences during your shift is
like writing a story with a beginning, a
middle and an end (each needs to be
accurately depicted in the record)

The physician relies on documentation
in order to make adjustments to the
plan of care
The record must reflect the physical
and mental status of the patient upon
admission and changes during the stay
in the facility. This will help serve as a
tool to identify the changing care needs
of the patient.

Keep the purpose of your entry in your mind
Summary of general observations
Identification of specific problems
Follow-up of previously identified
problems
Don’t leave the next reader in suspense and
wondering what happened. When you have
identified a problem, follow-up later to
include the status at the end of your shift.
Be descriptive and concise

Your notes should be:
Objective, not critical or subjective
Clear, concise, and comprehensive
Accurate, truthful and honest;
documentation should not appear
self-serving, especially if an incident
or injury occurs
Reflective of observations, not of
unfounded conclusions

Copyright © 2013 All Rights Reserved 28Harmony Healthcare International, Inc.
Medicare Nursing Documentation
Goal: Skilled nursing documentation
should clearly delineate the medical
complexity of the patient and skilled
nursing services provided

Medicare Documentation
There are increased reviews nationally
These are often focused on patients that
do not reflect skilled levels of care (e.g.,
those in the lower 14 RUG-IV groups)
There is an increase in the likelihood
that someone will review your
Medicare documentation

Medicare Nursing Documentation
The key to documenting skilled
services is understanding the Medicare
coverage requirements
Key Point: Nursing Rules the World!
Skilled Nursing Services anchor ALL
Part A benefits

Skilled Nursing Documentation 101
Skilled Nursing Documentation falls
under the following categories:
Direct Nursing Skills
Skilled Observation and Assessment
Management of a Care Plan
Teaching and Training Activities

Skilled Nursing Documentation
Some questions to answer in your notes:
Why does the patient require 24 hour
care in the SNF?
What does the nurse do to ensure
medical safety and promote recovery?
What patient issues require licensed
nurse intervention?
Key Point: Nursing always anchors
skilled care!

What To Consider Including:
Patient is at high risk for …
Skilled assessment of …
Daily skilled monitoring of …
Potential for recurrence of …
Potential for the following complications…
There is a likelihood of change related to…
The medical regimen is not essentially
stabilized as evidenced by…

Patient continues to require daily skilled rehab
for …
Observation and assessment for potential
complications related to …
Potential for medical complications related to
the diagnosis of …
Plan of care is being monitored to promote
recovery and ensure medical safety related to …
The patient requires daily skilled management
and evaluation of the plan of care related to …

Skilled neurological assessment resulted in…
Daily skilled monitoring for signs and symptoms
of exacerbation of _____ secondary to _______.
Patient is high risk for ______ secondary to
_______.
Medications adjusted to _____________, ongoing
skilled assessment of regimen to promote
recovery and ensure medical safety.
Patient continues to require daily skilled nursing
as his treatment regimen is not essentially
stabilized and there is a potential for recurrence
of ________.

Non-Supportive Nursing
Documentation
Plateau in progress
Voiced no complaints
Patient requires custodial
care
Patient requires
intermittent care
Patient is unable to
follow directions
Patient requires
intermittent services
Patient has poor
rehabilitation potential
Patients medical
treatment is essentially
stabilized
Refuses to participate in
therapy (instead give the
reason the patient is
unable)
Condition stable
Slept well/family into
visit

Daily Nurses Note
Describe a skilled observation,
assessment and/or action
This note can be episodic
Describe pertinent skilled
happenings of the day or shift

Daily Narrative Documentation
Should evidence the critical thinking,
judgment decision making by skilled
nurses
Daily nursing notes should evidence
assessment of the data recorded on flow
sheets and treatment sheets etc. vs. re-
stating the data

Documentation must justify the
clinical reasons and medical
necessity for:
Medicare Part A coverage
The skilled services being
delivered
The on-going need for coverage

Diagnosis Driven
Diagnosis related to acute
hospitalizations
Those which arose at the SNF
Chronic conditions that potentially
complicate the patient’s clinical
status, stability or level of care
needed

Admission and Re-Admission Nursing Notes
Admission Nursing Note:
Follows the admission nursing
assessment and is based on those
findings
Is done by the nurse admitting the
patient
Incorporates information in referral and
assessment data
This nurse knows more about the patient
than any other nurse will for several days

HHI suggests that the following information be
included in all Admission Notes:
Exact time and date of admission
Room number
Location prior to admission
Age, primary diagnosis, other pertinent medical
history
Assist level and number of assist with transfers
and bed mobility provided by staff (2 assist to
transfer)
List any identified skilled needs which have
been identified

HHI suggests that the following information be
included in all Admission Notes (Cont.)
Prior level of functioning and if possible, discharge
destination
List of all nursing assessments which relate to the
primary diagnosis and related secondary diagnosis
Detailed skin assessment and historic skin staging
reported
Most ADL care provided (Bed mobility, Eating,
Transfer, Toilet use) during the shift

The Bottom Line
Will the documentation in the
patient’s medical record support
the care and/or services provided
to the patient as well as the coding
on the MDS (which resulted in the
daily rate for the care of that
patient)?

Review of a Few Key
MDS 3.0 Sections

MDS 3.0
Section D:
MOOD

Section D: Mood
Intent: The items in this section address
mood distress, a serious condition that is
underdiagnosed and undertreated in the
nursing home and is associated with
significant morbidity
It is particularly important to identify signs
and symptoms of mood distress among
nursing home residents because these signs
and symptoms can be treatable

A Key Point from the
RAI Manual
…the presence of indicators in Section
D does not automatically mean that the
resident has a diagnosis of depression
or other mood disorder.
Assessors do not make or assign a
diagnosis in Section D, they simply
record the presence or absence of
specific clinical mood indicators.

Section D – Key Points
PHQ-9OV (staff assessment) should
include information from all shifts and
disciplines
Follow the interview script
Use the cue cards
Use the interview techniques from
Appendix D of the RAI Users Manual
Competency checks for interviewing staff

Section D – Key Points
Section D has a potential impact on
Percent of Residents Who Have
Depressive Symptoms (Long Stay)
Total Severity Score 10+, and
Little interest or pleasure in doing
things OR feeling or appearing down,
depressed, or hopeless half or more of
the days in the last two weeks (2, 3)

Section D – Key Points For Nurses
Documentation of follow up with patient to
talk about areas that are responded to
positively and are increased from last
assessment
Care planning for mood items
Daily/weekly documentation about symptom
prevalence and the efficacy of medications
Gradual Dose Reduction, when appropriate
Documentation of nursing support in relation
to mood symptoms and patient response

MDS 3.0
Section E:
BEHAVIOR

Section E: Behavior
Intent: The items in this section identifies
behavioral symptoms in the last seven days
that causes:
Distress to the resident
Distressing or disruptive to facility residents, staff
members or the care environment
This section focuses on the resident’s actions
and not the intent of the behavior

E0200: Behavioral Symptom
Presence & Frequency Behaviors
Physically Behavioral symptoms
directed toward others: Hitting,
kicking, pushing, scratching, or sexually
abusing others
Verbally Behavioral symptoms
directed toward others: Threatening
others, screaming at others, or cursing
at others

E0200: Behavioral Symptom
Presence & Frequency
Other behavior symptoms not directed
toward others: Hitting, scratching self,
pacing, rummaging, public sexual acts,
disrobing in public, throwing or
smearing food or bodily waste,
verbal/vocal symptoms like screaming,
disruptive sounds

E: Behavior
Section E also captures the effect the
behavior has upon the resident, and
upon other residents
Captures if the behavior puts the
resident or others at risk for
Physical injury
Affects privacy
Disrupts living environment

Section E – Key Points For Nurses
Section E is often under coded
Usual is not normal!
Documentation in the medical record
must support coding on the MDS
Behavioral management programs and
Management and Evaluation of the Plan
of Care must be captured in skilled
nursing documentation

Section E – Key Points
Surveyor Quality Measures:
Prevalence of Psychoactive Medication
Use, in the Absence of Psychotic or Related
Conditions (Long)—affects exclusions
Prevalence of Antipsychotic/Hypnotic Use
(Long)—affects exclusions
Prevalence of Behavior Symptoms
Affecting Others (Long)

MDS 3.0
Section G:
FUNCTIONAL STATUS

Section G:
Principles of Accurate Assessment
7-day look-back period (since admission or
readmission only)
Assess
Observe
Consult with all interdisciplinary team
across all shifts to capture accurate assist
levels
Ask probing questions, beginning with the
general and proceeding to the more specific

Section G:
Principles of Accurate Assessment
Do NOT include assistance provided by
family or other visitors when capturing
assist level
Do NOT code ambulance transfer
assistance or assistance from hospice
Code assist provided by facility staff
only
No longer looks back into the hospital

The Four Late Loss Activities of
Daily Living (ADLs)
Bed Mobility
Transfer
Eating
Toilet Use

The Late Loss ADLs Defined
Bed mobility - how resident moves to
and from lying position, turns side to
side, and positions body while in bed or
alternate sleep furniture
Transfer - how resident moves between
surfaces including to or from: bed,
chair, wheelchair, standing position
(excludes to/from bath/toilet)

The Late Loss ADLs Defined
Eating - how resident eats and drinks, regardless
of skill. Do not include eating/drinking during
medication pass. Includes intake of nourishment
by other means (e.g., tube feeding, total
parenteral nutrition, IV fluids administered for
nutrition or hydration)
Toilet use - how resident uses the toilet room,
commode, bedpan, or urinal; transfers on/off
toilet; cleanses self after elimination; changes pad;
manages ostomy or catheter; and adjusts clothes.
Do not include emptying of bedpan, urinal,
bedside commode, catheter bag or ostomy bag

Section G – Key Points For Nurses
Documentation to support coding is a must
Focus on four late loss ADLs
Accuracy begins at the bedside with the C.N.A.
all three shifts (don’t forget nights!)
Ensure reporting and/or documentation all other
disciplines regarding ADLs
Educate frontline nursing staff as well as IDT
Ensure an audit protocol (MDS and
documentation)

Section G – Key Points
Section G coding affects several QMs, as
covariates, exclusions, or triggers
Long Stay, Short Stay, and Surveyor
Measures
Daily documentation to support ADL
assistance provided is critical in
ensuring accurate and supported RUG-
IV classification

Quality Measures:
Percent of Residents with Pressure Ulcers That
Are New or Worsened (Short)—covariate
Percent of High-Risk Residents With Pressure
Ulcers (Long)—stratification to define high-
risk
Percent of Low Risk Residents Who Lose
Control of Their Bowel or Bladder (Long)—
exclusion of high risk to identify low

Quality Measures (cont.)
Percent of Residents Whose Need for Help
with Activities of Daily Living Has
Increased (Long)—trigger and exclusion

MDS 3.0
Section I:
ACTIVE
DIAGNOSES

Section I: Coding Instructions
Code diseases that have a documented
diagnosis in the last 60 days and have a
relationship to any of the following in the
last 7 days:
Functional status
Cognitive status
Mood or behavior status
Medical treatments
Nursing monitoring
Risk of death

A Two-Step Process:
• Diagnosis identification (Step 1) is a 60-
day look-back period
• Determining diagnosis status: Active or
Inactive (Step 2) is a 7-day look-back
period (except for Item I2300 UTI,
which does not use the active 7-day
look-back period)

Do not include conditions that
Have been resolved or
No longer affect the
resident’s functioning or plan
of care

Section I – Key Points For Nurses
Ensuring provider documentation to
support coding
Is physician documentation needed to
add to support to the diagnosis is active
in the last seven days?
Documentation (including care
planning) to reflect actively impacting
care of the resident

Section I – Key Points
Quality Measures for Antipsychotic,
Antianxiety, and Hypnotic use have
several diagnosis-based exclusions and
covariates
Diagnosis-driven daily documentation
to support the inherent complexity of
the patients condition and the need for
ongoing skilled nursing observation
and assessment

MDS 3.0
Section M:
SKIN CONDITIONS

Section M: Skin Conditions
Asks the clinician to determine if at risk
for pressure ulcers
Includes updated pressure ulcer
definitions
Must determine present on admission
Includes diabetic foot wounds
No longer back stage pressure ulcers
Only stage pressure ulcers

Section M – Key Points
Clear, concise, and accurate
documentation of all skin areas as soon
as possible after admission
Measuring practices and staging
competency
Determination and documentation of
wound etiology (scope of practice and
QOC issues)

Section M: Key Points For Nurses
Accuracy in wound documentation
Clear and descriptive wound
documentation
Patient’s response to treatment (pain,
infection, healing process)
Daily documentation that supports the
overall clinical picture of the wound

Section M – Key Points
Percent of Residents with Pressure
Ulcers that are New or Worsened
(Short)
Percent of High-Risk Residents With
Pressure Ulcers (Long)

MDS 3.0 Affect on Quality Measures
and the 5 Star Rating (Long Stay)
Percent of residents whose need for
help with daily activities has increased
Percent of high-risk residents with
pressure ulcers
Percent of residents who have/had a
catheter inserted and left in their
bladder
Percent of residents who were
physically restrained

and the 5 Star Rating
Quality Measures information is 100%
derived from MDS 3.0 data
There are 35 total Quality Measures (12
Short Stay, 23 Long Stay)
Nine of these Quality Measures will
influence your final 5 Star Rating (two
Short Stay, Seven Long Stay)
Four additional surveyor measures

and the 5 Star Rating (Long Stay)
Percent of residents with a UTI
Percent of residents who self-report
moderate to severe pain
Percent of residents experiencing one or
more falls with major injury

and the 5 Star Rating (Short Stay)
Percent of residents with pressure
ulcers that are new or worsened
Percent of residents who self-report
moderate to severe pain
MDS accuracy leads to Quality Measure
and 5 Star Rating accuracy!

Final Thoughts…
Daily skilled nursing documentation
must support the skilled services that
are being provided
Most claim denials are due to lack of
supportive clinical documentation

References
Medicare Program Integrity Manual, Chapter
6 http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/pi
m83c06.pdf
Medicare Benefit Policy Manual , Chapter 8
http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/bp1
02c08.pdf

References
5 Star Technical Users Guide
http://www.cms.gov/Medicare/Provider-
Enrollment-and-
Certification/CertificationandComplianc/dow
nloads/usersguide.pdf
Quality Measures Users Manual
http://www.cms.gov/Medicare/Quality-
Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/Dow
nloads/MDS-30-QM-Users-Manual-V60.pdf

References
RAI Users Manual
http://www.cms.gov/Medicare/Quality-
Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/
MDS30RAIManual.html

Questions/Answers
Harmony Healthcare Internationa
1 (800) 530 – 4413
kdutton@harmony-
healthcare.com
Harmony Healthcare International, Inc. 8888Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

Questions/Answers
Harmony Healthcare Internationa
1 (800) 530 – 4413
cdeschenes@harmony-
healthcare.com

Harmony Healthcare International
Have you Considered a Customized Complimentary
HARMONY(HHI) MEDICARE PROGRAM
EVALUATION
or
CASE MIX ANALYSIS
for your Facility?
Perhaps your facility has potential for additional revenue
Assess your facility against key indicators and national norms
Email us at for more information
RUGS@harmony-healthcare.com
Analysis is cost & obligation free

Nursing Documentation: Do Your Medical Records Support Skilled Care?

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

En vedette

En vedette (20)

Similaire à Nursing Documentation: Do Your Medical Records Support Skilled Care?

Similaire à Nursing Documentation: Do Your Medical Records Support Skilled Care? (20)

Plus de Harmony Healthcare International (HHI)

Plus de Harmony Healthcare International (HHI) (20)

Dernier

Dernier (20)

Nursing Documentation: Do Your Medical Records Support Skilled Care?