THE
SURVEYOR
I SPRING 2014
DOCUMENTATION:
MORE IMPORTANT THAN EVER BEFORE
LISA MEADOWS, ACHC CLINICAL EDUCATOR FOR HOME HEALTH, HOSPICE AND PRIVATE DUTY
We have all heard “If it’s not documented, it’s not done,” but how much
can poor documentation impact a healthcare agency?
The answer is, quite a lot. First and foremost, careless or
inaccurate documentation can jeopardize patient safety.
From a fiscal perspective, it can also lead to improper
billing and reimbursement, and potentially result in fines
or other unplanned financial consequences.
Many clinicians can relate to the implications of poor
documentation as it pertains to patient care, as many
have had to provide care to a patient when left with
inadequate clinical note information. However, few have
had to justify their documentation during an Additional
Documentation Request (ADR), when the clinicians’
notes are vital in validating reimbursement.
CMS has recently revised Chapter 7 of the Medicare
Benefit Policy Manual for Home Health Services to
provide additional clarification on the appropriate
documentation necessary to support the need for
skilled services.
Section 40.1.1, General Principles Governing Reasonable
and Necessary Skilled Nursing Care, reviews the
necessity of accurate documentation, especially on the
individualized patient assessment, to support the need
for skilled nursing services. Skilled nursing services
are covered “…when an individualized assessment
of the patient’s clinical condition demonstrates that
the specialized judgment, knowledge, and skills of a
registered nurse or, when provided by regulation, a
licensed practical (vocational) nurse (‘skilled care’)
are necessary. However, when the individualized
assessment does not demonstrate such a necessity for
skilled care, including when the services needed do not
require skilled nursing care because they could safely
and effectively be performed by the patient or unskilled
caregivers, such services will not be covered under the
home health benefit.”
This section clarifies the specific information needed for
the individual clinical note documentation. Each clinical
note should justify the need for skilled care and “tell
the story” of the patient’s achievement towards his/her
goals as outlined in the plan of care.
10
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CMS specifies that each home health clinical note
must document as appropriate:
The history and physical exam pertinent to the day’s
visit, (including the response or changes in behavior
to previously administered skilled services) and the
skilled services applied on the current visit
The patient/caregiver’s response to the skilled
services provided
The plan for the next visit based on the rationale of
prior results
A detailed rationale that explains the need for
the skilled service in light of the patient’s overall
medical condition and experiences
The complexity of the service to be performed
Any other pertinent characteristics of the patient
or home
Documentation should also demonstrate the
“next steps” in the patient’s treatment as well as
pro