Regulations can be challenging, especially for small hospice organizations. Regulators scrutinize documentation for fraud and abuse and unnecessary care. Hospice administrators, clinicians, and IDG members must remember “if it wasn’t documented, it wasn’t done!” This blog post will address how to increase documentation confidence and achieve compliance.
Hospice Documentation Basics
Hospice care is for those individuals who need skilled palliation of end-of-life symptomology. Documentation needs to show that the hospice care is medically necessary and that the care is reasonable. Good documentation must start on admission and must be done throughout care. Documentation must be able to:
- Support hospice admission
- Support level of care
- Support the need for hospice services
- Show a decline in a patient’s condition
- Show interventions the hospice team is providing and the patient’s response to them
Effectively Documenting Patient Decline
Consistent and effective documentation by all team members is important. Checking with the hospice aide or hospice volunteer about changes in function can provide relative information to support patient decline. It is important to identify areas of need through interdisciplinary assessment and ensure the plan of care is updated and that interventions are documented at each visit for the respected discipline.
With the use of electronic medical records (EMRs) it is easy to get in the habit of using check-boxes and auto-populated responses across narratives and IDG notes; however, documentation needs to be individualized and needs to tell a story. Documentation should paint a picture so that anyone reading it has a clear picture of what the patient looks like. In order to paint a picture for a reviewer, documentation must include measurable objectives such as:
- Weights / mid-arm circumference / abdominal girth
- Lab values
- Food and fluid intake
- Specific signs and symptoms and information to support
- Example: Increased dyspnea as evidenced by increased use of accessory muscles on inspiration
- Using appropriate scales
- The Palliative Performance Scale (PPS)
- The Karnofsky Performance Scare (KPS)
- Functional Assessment Scale (FAST) if patent has a diagnosis of Alzheimer’s / Dementia
- Activity level including self-care
- Skin issues
- Infections / treatments
With documentation being detailed and descriptive, it will decrease your risk of scrutiny from a reviewer. Remember, a clinical record should be like a novel, but not a mystery novel.
Have Questions? We Have the Answers!
Our team at 5 Star Consultants is very knowledgeable about documentation and practice standards to help you withstand scrutiny. Contact us today! We welcome the opportunity to speak with you about your training needs and the different solutions we offer. Please feel free to contact us at [email protected] or 866-428-4040.