If you haven’t already done so, take the ‘Write it Right’ quiz and then return here for the answers. If you have already taken the quiz, proceed with caution. The answers are below.
Q. Which of the following best describes a patient who is homebound?
A. Unable to walk without assistance and becomes confused when leaving the home.
76 percent of you answered this question correctly. The key word is ‘and’. There are two parts to documenting homebound status. The patient must have a physical or mental condition that makes it difficult to leave the home and the patient must unable to tolerate leaving home without some degree of difficulty.
Q. The claim for a medical record for a patient discharged from rehab following hip surgery would likely be denied for which of the following charting errors.
A. No short and long term goals.
Susan J pointed out that this requirement is only held by Palmetto GBA. Other MACs, RACs and contractors do not follow this strict interpretation of the coverage guidelines. Regardless, 89 percent of you are looking for short and long term goals in therapy assessments.
Q. Every visit note must address the primary diagnosis.
63 percent of you marked, ‘true’ for this T/F question and 63 percent of you are incorrect. I think this stems from claims where high dollar primary diagnoses are not supported in the visit notes and denials ensued.
Most of your documentation, in normal circumstances should be related to the primary diagnosis. Having said that, I have read notes that read something to the effect of, ‘Patient on floor upon arrival complaining of chest pain. Taught that diabetic foot care was important to prevent amputations.’
If you read the care plan and understand what is supposed to be happening but feel like something else takes precedence, by all means, document according to the patient needs and your response.
Q. When writing a plan of care, the nurse should always:
A. Write vital sign, pain and lab parameters that call for MD notification.
Coordination of care is one of the most frequently cited deficiencies on state surveys. Having parameters on the careplan is not only a ‘best practice’ but it also ensures that you have communication with the MD and frequently orders accompany that communication. When a patient has an exacerbation and the MD is notified and there are changes to the care plan, the patient remains eligible for services (i.e. you will get paid). MDs do not wake up mysteriously aware that their patient has a high blood pressure or continues to have pain. Tell them! Get Orders!
Half of you got this question correct. The other half thought it was a good idea to detail the content of teaching on the care plan. If you have ever seen a careplan where an episode’s worth of teaching is contained in the orders, you understand how easy it is to miss something else important in the care plan.
Nurses are expected to know how to find proper teaching material according to their agency policy. Since the 485 is a guide for the clinicians and not patients, writing details of teaching is unnecessary.
Q. When documenting, more is better.
A. Most of you realize that this statement is false but a quarter of you did not.
Documentation is often the only information you have about a patient. Decisions about patient care are made based upon prior documentation.What if you are seeing a patient for the first time because a nurse is on vacation and upon arrival at the home, the patient is hardly awake and incoherent. Did they stroke? Is there a problem with the blood pressure? What meds are they on? Were there any changes? How’s that blood pressure doing?
These are all questions that might run through your mind. As soon as you could safely do so, you would read through the last few visit notes to see what exactly has been going on with the patient. You would not want to read through pages of notes that restate an assessment and offer other information that was irrelevant (pasted teaching advising the patient to avoid contact sports and use birth control). What you need to know is what has happened recently; Med changes, MD appointments, the usual condition upon arrival.
When you document, cut to the chase. Be ruthless with your editing without taking away from the picture you are painting.
Q. Documentation of wounds should include on every visit note:
A. location, size, nature of drainage (color, odor, consistency, and quantity), and condition and appearance of the surrounding skin.
I apologize for this question. The answer is cut and pasted directly from the Medicare Benefit Coverage manual but whenever 83 percent of people who take the quiz get it wrong, it is time to look at the question and not the respondents.
There are some valid points, though. While Medicare doesn’t specify that the origin of a wound be in the wound care documentation, a good nurse would expect to see it. Perhaps Medicare was assuming that the wound would be in the diagnosis coding.
Wounds are not always staged and LPN’s do not stage wounds. As such, the stage of the wound is not critical to wound care documentation. And wound care orders only need to be followed – not restated in documentation.
Congrats to the 17 percent who answered correctly. The rest of you can take solace in that I learned a little about writing quiz questions.
Q. What must be present to document and exacerbation of an illness or condition?
A. The answer is ‘all of the above’ which included: increased symptoms or new symptoms, MD notification and a change to the plan of care.
Years ago, this was written somewhere. I can no longer find it written out as I remember it but I read support for this definition in claims denials. These denials note that there have been no new orders or meds, no hospitalizations, no communication with the MD and no changes to the plan of care. Denials will also mention when a patient has increased symptoms but the MD did not write orders; thus the plan of care was not changed. If indicated, ask for a PRN visit on those occasions when the physician is not ready to change orders because of an isolated event.
Q. What must be present on plans of care accompanying a recertification?
A. An estimate of how muchlonger services will be required from the MD.
The fact that only 70 percent of you got this question right means that 30 percent of you will have difficulties should your chart be reviewed in the future. This is not new but review of this requirement only began for episodes beginning in August of last year. The PPS update for 2015 stated:
When there is a continuous need for home health care after an initial 60-day episode of care, a physician is also required to recertify the patient’s eligibility for the home health benefit. In accordance with § 424.22(b), a recertification is required at least every 60 days, preferably at the time the plan is reviewed, and must be signed and dated by the physician who reviews the plan of care. In recertifying the patient’s eligibility for the home health benefit, the recertification must indicate the continuing need for skilled services and estimate how much longer the skilled services will be required.
Q. Which of the following is the best example of teaching and training for a patient who has been on service more than one episode?
A. Pt. has a new caregiver who is not confident with wound care. Technique taught to new caregiver.
90 percent of you got this right. If you are one of the 10 percent, keep in mind that you should always document the reason why reteaching is required and it shouldn’t suggest that it is because a patient cannot or will not learn.
Q. When documenting pain, which is true?
A. A self-rated score of 7 or higher indicates severe pain and best practices indicate the MD should be called.
The good news is that 92 percent you know this. The bad news is that the hateful eight percent are still documenting ‘MD aware’ and not doing anything for the pain.
Q. Documentation for people taking coumadin should include:
A. Orders for INRs or a notation that you verified with the MD that INRs are being drawn at the office.
70 percent of you answered correctly. This is not technically a coverage question but I included it as a reminder that Coumadin is a deadly drug and that failure to monitor it can be fatal. Even when not fatal to the patient, it can be fatal to your career. ASK for orders or to have lab faxed over. Be sure it was done. When a patient is harmed, it no longer matters who’s at fault. Chances are your physicians will be grateful you are covering their backs.
Q. It is not necessary to include a review of the physical assessment in the narrative portion of your visit note.
This is true in stark contrast to the 52 percent of you who had this wrong. We’ve already covered this but one more time – More is not better when it comes to charting. Cut to the chase. Make it relevant and useful. There is no bonus for extra words.
If you are concerned that your documentation might not consistently result in payment, there is an answer that costs less than even one denial. Call us today to set up a coverage and documentation inservice.