Why do I have to document?

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Documentation is key to communication with other members of the health care team including other nurses, physicians, therapists, aides, dietitians, pharmacists, etc. It is also vital to improved patient outcomes and the quality of patient care as well as continuity of care.
Nurses often complain that documentation takes away from actual caring for patients and they resent having to do so much paperwork. Without documentation however, patient care and outcomes can be completely compromised and the Nursing Process weakened. Documentation is a necessity for reimbursement and must show the homebound status, the skilled need, the goals, measurable gains, and outcomes. All care must be ordered by a physician, NP or PA and must be followed by the nurse, therapist or social worker.
ADRs are
Additional Development Requests (also known was Additional Documentation Requests) from the payor source. Medicare and private insurance companies can request a copy of the chart for their own QA or utilization review to ensure the payment is appropriate and to prevent FRAUD and Abuse. They can and will possibly deny reimbursement based on the findings. It is essential to document the Homebound status and Skilled Need (medical necessity) at EACH visit. There must be signed orders for all care and any missed visits. The care has to match the orders and the frequency. Measurable gains and goals need to be clearly stated and Outcomes must show progress. Once a patient plateaus or no longer makes progress towards goals or gains, it's time to discharge. Once the patient is no longer homebound, it's time to discharge. Each visit note MUST be unique to the patient and demonstrate all of the above in order to be reimbursed for care.

If the chart is found to be lacking in any of this information, the Medicare review or insurance review may deny claims, and require repayment if the claim has already been paid. If the number of claims denied exceeds specific limitations (usually 10% of the total charts in the review), the reviewer can put an agency on full medical review and every chart will be required to be reviewed prior to payment. This puts significant pressure on the agency to review all of the paperwork and prepare the files for transmission before sending it, and financial strains will be created by a much slower flow of payments. If the agency doesn't get paid, you won't get paid!

OIG, among other agencies, has been tasked by the government to ensure payments are appropriate and that the agency has not committed any FRAUD or Abuse. In other words, they are tasked with finding instances where money can be recovered.

ADRs can be issued for past as well as current charts. These are legal documents and must contain specific information about the patients, the visits, the oversight from the ordering physician along with the necessary Face-to-Face information, the progress towards goals and gains along with the homebound status and skilled need. Documentation is not just an inconvenience. It is a necessity for every home health care agency to thrive and survive. The documentation need to be unique to each patient. A chart that is 2-5 years old can be exceedingly challenging if the documentation is not pristine. That nurse or therapist may no longer be employed by the agency, dashing any hopes of interpretation of illegible handwriting or understanding what took place. Complete and thorough documentation is an essential aspect of home health care.

Here's an Example
Although this is an example from hospital care, something similar could happen in the home care environment as well if there is not adequate communication between disciplines and colleagues. 
Assume for a moment that you only had to rely on what the nurse (Amy) told you during report or rounds. She's distracted and in a hurry because she's leaving after work for a 3-day cruise. Amy forgot to tell you that your patient, Mrs. B, developed a rash all over her body when given her antibiotic this morning and the medication has been changed.

Amy also forgot to tell you that the dressing on her abdomen needs to be changed soon because she didn't get to it today and it should be changed BID. And, oh yes, Amy also neglected to tell you that Mrs B fell in the bathroom and bumped her head a few hours ago, but had no immediate ill effects. The doctor was called and a message left with his nurse. He'll be in for rounds at 6 PM.

You enter Mrs. B's room and find that she is feeling nauseous and dizzy and has a headache. You instruct her to try to lay still and rest. You check her dressing and find it saturated. Mrs. B tells you she is “still a bit itchy.” [Itchy from what?] Mrs. B doesn't know, but she's been itchy all day and she told the day nurse (Amy) about it. She has a rash all over her abdomen. It's pale pink, but is it fading or just budding? Is it related to something such as a medication?

Immediate Jeopardy?
These are all new findings and need to be reported to the doctor. He's very perturbed with you that you don't know about the fall and how long she has had her rash symptoms. He can't understand why you don't know about her reaction to the antibiotic this morning. How long has she had the rash? You can't tell him when the last dressing change was done either, but you assume it was in the morning, so this seems to be a significant increase in drainage.

You can't reach Amy, she's left for her 3-day cruise. No one from the previous shift is still around. The patient, Mrs. B, is forgetful and becoming somewhat confused. She knows who she is and where she is, but she thinks it's morning and she just woke up. Mrs. B also thinks it's Tuesday and it's Friday. Has she been confused for awhile or is this also new?

You haven't worked in three days and Mrs. B is new to you. None of your team today knows her. Wouldn't a chart be helpful? Documentation does indeed take time, but it is so very important to patient care and continuity.

Home health care is intermittent and you don't want to have to reinvent the wheel at each visit. Thorough documentation of what the patient has been taught, return demonstrated and what goals have been met already is the most valuable tool you have. You may have all of this information in your head, but if you're not the one making the next visit, it can be difficult to provide continuity of care and efficient use of your time as well as the patient's. Any reviewer won't have any idea of all that has transpired either if it's not written in the chart.

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