Nursing Documentation to Support Medical Necessity Lisa Werner Bazemore, MBA, MS, CCC-SLP Director of Consulting Services

Medical Necessity Basic Principles  Service must be reasonable and necessary (in terms of efficacy and, duration, frequency, and amount) for the treatment of the patient’s condition  It must be reasonable and necessary to furnish the care on an inpatient hospital basis, rather than less intensive facility such as a Skilled Nursing Facility, or on an outpatient basis

Medical Necessity  Services are relevant to a patient’s diagnosis, symptoms, condition or injury  Services provided are within the standards of practice for a specific condition or diagnosis  Services require the skills of the specific professionals within your setting  Services that are provided in your setting possibly would not be furnished in the same quality or quantity or time frame in another setting  Services treat a condition which could result in physical or mental disability

Team Documentation What can the non-physician provider do to support medical necessity?  Ensure documentation is legible and easy to navigate. Auditors review many charts each day. They will not struggle to decipher and organize therapy documentation to establish the medical necessity of services.  Use only medically accepted abbreviations  Follow good medical integrity practices for corrections and for documenting late entries.

Team Documentation Proving necessity of the skilled service:  Reviewers look for evidence that the patient requires continued skilled services. This is shown through the treatment/progress notes: Write progress notes that clearly explain the skilled services delivered in each treatment session.

Plan of Care Medicare wants to see the treatment plan is determined by and coordinated by the physician  Admission Orders Should indicate all therapeutic disciplines ordered – INCLUDING Rehabilitation Nursing  If “evaluate and treat” must follow up with a clarification order  If specific interventions are indicated the disciplines MUST have them in their plan of care  Clarification Orders Need to be signed by the physician Should indicate frequency and duration as well as all possible interventions

Plan of Care Plan of Care is a individual discipline or multidisciplinary document that outlines the patients problems, proposed interventions and goals. The Plan of Care serves many needs:  Communication  Meeting requirements of Medicare & Insurance Companies – multidisciplinary team JCAHO – Prioritization of problems CARF – Reflects the goals of the persons served Facility – ???

Plan of Care Purpose of the plan of care:  To communicate patient goals & expected outcomes to the team & family  To communicate to the patient & family what they can expect each team member to be doing to help meet the interdisciplinary goals  To communicate interdisciplinary treatment goals, expected outcomes & summary of progress to the patient  To communicate interdisciplinary treatment goals, expected outcomes, & summary of progress to payer sources  To provide a means to alter the initial treatment plan, as appropriate  To facilitate family participation in the rehab process  To document the patient’s progress in his/her rehabilitation program

Plan of Care Purpose of the plan of care: (cont’d)  Documentation that is interdisciplinary Created by all components of the rehab treatment team Collaboration among team members, including patient, determines team goals Is agreed upon by all parties  Derived from the team assessment and patient expectations  Clearly identifies long and short term goals  Defines how disciplines share responsibilities for the efficient & effective goal attainment by the patient  Supports the need for intensive inpatient rehab services

Plan of Care How does the information flow?  Pre-admission screening form gathers information on actively treated conditions and history of the present illness  Physician reviews pre-admission screening and acute records  Physician does assessment  Clinicians reference pre-admission screening, acute records, and physician documentation prior to assessing the patient  Clinicians do assessments  Clinicians develop discipline specific goals  Team coordinates to align patient and discipline specific goals into overarching team goals  Team coordinates and implements a multidisciplinary plan of care to achieve overarching team goals.

Plan of Care How do you develop a plan of care?  Physician plan drives the plan of care for clinicians  All clinicians document consistent findings  Goals are clear, measurable, functional How do you document the plan of care?  All clinicians document on the same form (Best Practice)  Everyone is aware of the team goals and supports them through treatment

Plan of Care Establishing barriers:  Plan of care should answer these questions: Why does the patient need a stay in inpatient rehabilitation? What difference will inpatient rehabilitation make in this patient’s quality of life?  Problem list: List the problems requiring post-acute services Indicate which professionals will work on reducing the barriers Set goals for how much progress will be made Indicate time frame for resolving the barriers

Plan of Care Framework of the plan of care:  Roles: Neuropsychology Nursing Nutrition Physical Therapy Occupational Therapy Social Work Speech Therapy Therapeutic Recreation  Each clinician has discipline specific things to work on  These tasks overlap with other clinicians  How do you represent this on your plan of care?

Plan of Care Goal setting:  Team goals (long-term) Represent what it will take for the patient to reach their discharge goal Will require care or carry-over from the team to achieve  Discipline specific goals (short-term) Should link to long-term team goals Must be objective

Plan of Care  Includes a review of current situation: Vitals Medications Allergies Social history  Review of systems: Cardiovascular Musculoskeletal Neurological Pulmonary Gastrointestinal Renal/Genirourinary Skin Nutrition Nursing Admission Assessment:

Plan of Care  Concludes with a problem list Impaired mobility Self-care deficits Altered urinary elimination Altered bowel elimination Potential for injury Activity intolerance Impaired skin integrity Impaired communication Impaired swallowing Altered nutrition Pain Altered thought process Unilateral neglect Ineffective airway clearance Others? Nursing Admission Assessment:

Plan of Care Nursing Admission Assessment:  Consideration: IRF specific assessment vs. house-wide assessment What are the differences?  Review of current status?  Review of systems?  Problem list? Where does it come together?  Plan of Care How does it come together?  Use the findings in the assessment to develop goals  Determine what is most important to the patient  Use judgment to assess the factors that will most significantly impact the patient’s ability to return to independence

Plan of Care Sample nursing goals:  Patient will be continent of bladder/bowel ____ % of the time.  Patient will remain free from UTI.  Patient will understand and comply with ____diet restrictions.  Patient will improve/maintain protein status.  Patient will improve/maintain oral intake by consuming ____ % of meals.  Patient will improve/maintain weight at ____ % of ideal body weight.  Patient will meet nutritional needs to promote wound healing.  Patient/caregiver will verbalize understanding and demonstrate pressure relief techniques.  Patient will understand and demonstrate pain relief techniques.

Plan of Care Team Admission Assessment:  Social Work/Case Management Prior level of function Living situation and needs Equipment haves and have nots Emotional concerns Preferences Discharge plan GOALS!

Plan of Care Sample social work/case management goals:  Patient will be discharged _________ with the necessary equipment.  Patient will be discharged with the necessary services.  Patient/caregiver will be educated on the patient’s condition and needs prior to discharge.  Patient/caregiver will demonstrate an understanding of appropriate and available community resources.

Plan of Care Team Admission Assessment:  Occupational Therapy – Eating Grooming Bathing Dressing/clothing management Toileting Toilet transfers Tub/shower transfers Home management Cognition Upper extremity range of motion and strength Sensation, tone, balance, motor planning and control, perception Pain

Plan of Care Sample Occupational Therapy goals:  Patient will feed self with ___ level of assistance.  Patient will perform grooming tasks seated/standing with ___ level of assistance.  Patient will follow ___ step command to assist with ADLs ___ % of the time.  Patient will shower/sponge bath with ____ assistance seated/standing with ______ assistive device and _____ DME.  Patient will complete upper body (or lower body) dressing with _____ assistance using ______ assistive device.  Patient will transfer to/from toilet with ______ assistance using _____ equipment.  Patient will verbalize solutions to safety situations ____ % of the time.

Plan of Care Team Admission Assessment:  Physical Therapy – Bed mobility Transfers Locomotion Stairs Sensation, tone, balance, motor planning and control, perception Pain Ability to participate and learn

Plan of Care Sample Physical Therapy goals:  Patient will perform bed mobility with ____ assistance.  Patient will transfer to/from the bed to wheelchair/stand with ____ assistance and ____ assistive device.  Patient will transfer to/from the car with ____ assistance and _____ equipment.  Patient will walk/operate wheelchair _____ feet with ____ assistance using ______ device.  Patient will negotiate ___ stairs/curbs with ____ assistance using _____ equipment.

Plan of Care Team Admission Assessment:  Speech Therapy – Eating and swallowing Comprehension Expression Problem solving Memory Speech intelligibility Executive functioning Pain Ability to learn

Plan of Care Sample Speech Therapy goals:  Patient will consume least restrictive diet without signs or symptoms of dysphagia ____ % of the time.  Patient will exhibit functional lingual and labial strength and range of motion.  Patient will comprehend complex information at the word/sentence/conversation level _____ % of the time.  Patient will answer yes and no/open ended questions to improve communication with others ___ % of the time.  Patient will communicate needs at ____ level to all partners _____ % of the time.  Patient will demonstrate short-term memory skills at ____ level.  Patient will remember treatment schedule and visitors with ___ % accuracy.

Plan of Care Team Admission Assessment:  Neuropsychology – Adjustment Social interaction Memory Problem solving Pain management

Plan of Care  Patient will demonstrate problem solving skills in all disciplines with ____ % accuracy.  Patient will remember treatment schedule and visitors with ____ % accuracy.  Patient will verbalize solutions to safety situations ____ % of the time  Upon discharge patient will have participated in 1 Ther Rec program and / or demonstrate good social skills with patients and staff.  Patient will have decreased depression by ___ %.  Patient will have decreased anxiety by ___ %.  Patient will demonstrate increased motivation to participate in activities.  Patient will increase and apply their strategies for pain management. Sample Neuropsychology goals:

Plan of Care Team Admission Assessment:  Therapeutic Recreation – Community reintegration Social interaction Home management Adjustment to disability Orientation

Plan of Care Sample Therapeutic Recreation goals:  Patient will remember treatment schedule and visitors with ____ % accuracy.  Patient will verbalize solutions to safety situations ____ % of the time  Upon discharge patient will have participated in 1 Ther Rec program and / or demonstrate good social skills with patients and staff.  Patient will be able to re-enter the community to enjoy / perform leisure activities based on current abilities.  Patient will be able to perform home management tasks based on current abilities.

Plan of Care Establishing team goals:  Must be important to patient, his/her family, and other members of the team  Must be associated with identified problem  Must have an impact on the patient’s health and quality of life  There must be strengths and resources available that can be mobilized to deal with the problem  Must be able to identify what needs to be done, who will do it, and when it will happen  Must be able to identify an expected outcome that can be expressed in measurable terms and with an expected timeframe  Must be complex enough to require the skills and commitment of multiple members of the team

Plan of Care – Team Goals Toileting: Ms. Smith will toilet with supervision.  OT will address toileting: clothing management and hygiene  PT will address ambulation with the walker in cluttered areas  ST will assist with developing a communication system to assist the patient with communicated the need to toilet.  Nursing will follow through with therapeutic techniques learned in PT/OT during the evening and the service aide will ask the patient if he or she needs to toilet when rounding  MD will order timed voids and adjust medications  All disciplines will enforce fluid restrictions, communicate accidents, and participate in assisting the patient with timed voids

Plan of Care – Team Goals Family Education: Mr. Brown’s family will demonstrate the ability to safely assist the patient with self-care and mobility with supervision prior to the next care team meeting.  ST will perform education on modifications to Mr. Brown’s diet  OT will perform education on assisting the patient with lower body dressing and toileting  PT will perform education on assisted ambulation  Nursing will perform education on medication management  Case Management will schedule family education sessions  All disciplines will complete thorough documentation on education completed noting barriers to effective education

Plan of Care – Team Goals Effective Communication: Mr. Smith will demonstrate the ability to follow one step commands from his spouse 75% of the time.  ST will provide education during the care team conference on effective modes of communication with Mr. Smith who has severe receptive aphasia  ST will initiate education on these strategies with the family  All team members will model these communication strategies with the patient to improve the patient and family’s ability to effectively communicate

Plan of Care – Team Goals Bladder Management: Ms. Jones will demonstrate bladder continence 100% of the time.  Nursing will develop and implement a timed void schedule. They will also educate the patient and family to the rationale and goal.  Therapies will adhere to the timed void schedule while the patient is in therapy.  Therapies will reinforce education provided by nursing when working with the patient/family.  Nutrition will work with the physician to limit or eliminate bladder stimulants like caffeine.  The physician will review the patient’s medications to see if any are likely to induce frequency and eliminate or change if possible.

Plan of Care Next steps  Plan of care should be the guiding force for treatment decisions throughout the stay Update weekly at team Ensure that team is on target with established goals Reorient team to long-term goals if treatment plan seems to be taking a different course Adjust plan of care goals as necessary

Team Documentation Ongoing documentation of skilled services:  Use skilled terminology and objective measurements in documentation to show functional progress and improved safety as a result of the delivery of skilled intervention. Examples include:  Assessment of performance  Adaptation of the task or environment  Training in the use of adaptive equipment  Use of specialized treatment techniques  Adjusting the treatment program as the patient's condition changes  Providing analysis of performance and skilled feedback on performance

Team Documentation Ongoing documentation of skilled services:  Document that the patient is able to follow directions, retains the skills learned, and shows carryover of the learned skills into other functional areas.  Justify the need to continue treatment based on progress, treatment goals, and functional level needed at discharge.  Explain any setback or lack of progress but supporting that the patient retains good potential to achieve the set goals.

Team Documentation Ongoing documentation of skilled services:  Specify when recommended orthotics or adaptive equipment arrived and were fitted, and the patient's response.  Explain complications such as the development of pressure areas after application of an orthotic to show improved patient safety from skin breakdown.  Address patient, family, and caregiver training and successful carryover of the tasks taught.  Ensure that documentation by other disciplines involved with the patient corroborates changing functional abilities as a result of clinical intervention.

Team Documentation Documentation near discharge:  Clinicians should train the patient, family, or caregivers during the entire course of treatment to facilitate carryover of skills taught in treatment.  The stay may not be continued after a plateau in performance skills has been reached for the sole purpose of training caregivers.  Treatment should not automatically be continued because skilled placement can not be found. Continued treatment can be supported if discontinuing treatment would compromise the patient's safety or health.

Team Documentation The goals of the team documentation are:  Tell the story of the patient’s stay  Communicate why you made the treatment decisions for care rendered  Indicate how the patient progressed  Present the barriers to discharge or safety concerns hroughout the stay  Let the service provider treating the patient next know what to expect

Team Documentation Team has an ongoing opportunity to document medical necessity. This is achieved by documenting:  That services needed are of a complex nature that they require a licensed clinician  Services are consistent with diagnosis, need, and medical condition  Services are consistent with the treatment plan  Services are reasonable and necessary  Patient is making progress towards reasonable goals

Nursing Documentation Rehabilitation nursing services are necessary 24/7  Nursing plan addresses rehabilitation needs of the patient  Supports medical management as laid out by physician  Addresses education needs of the patient  Establishes continuity of care among the team

Nursing Documentation Daily Documentation:  Flow Sheets  Functional Independence Measure Scoring  Narrative notes that state Care rendered Patient’s response to care Patient’s performs in areas where functional deficits exist  Transfers  Self care  Communication/cognition  Locomotion Education provided Patient/family’s response to education

Nursing Documentation Care rendered and patient’s response to care:  List types of care provided to patients during: Day shift Evening shift Night shift  We state that our patients require the skills of a rehab nurse 24 hours a day.  Does this sound like rehab nursing? “Patient resting comfortably in bed.” “Patient eating dinner with spouse at bedside” “Patient voices no complaints” “Doctor in to see patient, no new orders”

Nursing Documentation Care rendered and patient’s response to care:  How do we talk about skin integrity? Checked patient q2 hours for position of hemiparetic arm. Repositioned arm each time because patient is neglecting left arm. Reviewed pressure relief techniques with patient and caregiver this evening. Patient continues to forget to self-initiate repositioning when in his wheelchair. Healing noted by reduction of sacral wound size to xx cm. Patient observed using pressure relief techniques while in wheelchair today. Other examples?

Nursing Documentation Care rendered and patient’s response to care:  How do we talk about pain? Patient is maintaining a pain level of 3 by initiating the request for medication prior to therapy without reminders. Patient was supervision with transfers this shift, which he reports is related to pain reduction. Patient was unable to participate in therapy sessions this morning due to extreme pain. Continuing to monitor pain levels to achieve control that will allow participation in this afternoon’s program. Other examples?

Nursing Documentation Care rendered and patient’s response to care:  How do you talk about bladder and bowel elimination? Change of dosage of Detrol resulted in reduced bladder leakage. Patient did not have any accidents this shift, which is significantly improved from 2/21 when the patient experienced 3 bladder accidents in one shift. Patient had hard stool today. Will encourage increased fluid intake to 200 cc/hr and notify team to assist with fluid reminders. Due to frequent accidents, a q2 hour bladder program has been initiated. Patient alerts nurses for toileting at the top of the even hours in keeping with his bladder protocol. Other examples?

Nursing Documentation Care rendered and patient’s response to care:  How do we talk about safety? Patient attempted to get up to go to the bathroom without calling for help. Patient was reminded of limitations due to his recent surgery requiring him to be supervised with transfers and mobility. Patient indicated understanding of how to call for assistance. Due to increased confusion tonight, patient required frequent observation from nursing. He required checking every 30 minutes for safety. Patient required redirection about half of the time. Patient and family educated on the importance of close monitoring for basic needs to decrease the risk of the falls as patient tried to complete task unsupervised. Other examples?

Nursing Documentation Functional Status:  Notes should address functional performance in: Functional Independence Measure Flow Sheet Narrative Notes Shift Report  Keep your team goals in mind. How is the patient performing against established goals?  Include comments on the barriers to the patient’s independence

Nursing Documentation Functional Performance Examples:  Patient showed no signs and symptoms of aspiration while taking noon meds with nectar thick liquids.  Patient required moderate assistance while transferring to the toilet due to loss of balance.  Patient was reminded to keep his feet on the floor while transferring with sliding board as instructed by PT.  Patient experienced a bladder accident due to a urinal spill. Caregiver was needed to change the patient’s bed linens.  Patient required moderate assistance while bathing this morning due to increased pain. He was unable to wash lower extremities, buttocks, and perineal area.  Others?

Nursing Documentation Family/patient education examples:  Patient has not exhibited improved performance with external cath placement. Family is discouraged, but willing to continue education in order to assist the patient at home.  Patient demonstrating signs of difficulty adjusting to disability. Nurse provided support group information to patient and wife.  Patient and family educated on blood sugar testing and monitoring. Family performed task with nurse supervising. More instruction with finger sticks is required.  Patient/family continues to require education regarding medication administration and signs/symptoms of disease exacerbation.

Nursing Documentation Showing progress:  At least weekly, return to the established team goals.  Note where progress has been made by stating current status compared to prior status.  Review previous narrative notes to determine what burden of care was present earlier that is now resolved.  Indicate how nursing interventions resulted in a positive outcome.

Nursing Documentation At least weekly, a summary of the patient’s progress should be documented.  Document progress toward goals  Detail barriers to achievement of goals  Describe changes to the plan of care as appropriate  Describe patient’s response to treatment  State the justification for continued stay on the rehab unit

Questions? Lisa Werner Bazemore, MBA, MS, CCC-SLP