Improve Your Home Health Nursing Documentation

Transcription

1 Improve Your Home Health Nursing Documentation November 20, _0113

2 Today s Presenters Sally Rosiello RN, BSN 2 National Government Services, Inc.

3 Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at 3 National Government Services, Inc.

4 No Recording Attendees/Providers are never permitted to record (tape record or any other method) our educational events This applied to our webinars, teleconferences, live events and any other type of educational event 4 National Government Services, Inc.

5 Acronyms Acronym ADL BP CBC Cc CMS IADL IOM Mcg Mg Term Activities of daily living Blood pressure Complete blood count Cubic centimeters Centers for Medicare & Medicaid Services Instrumental activities of daily living Internet-Only Manual Micrograms Milligrams 5 National Government Services, Inc.

6 Acronyms Acronym MU NTG P PRN R SOB T Term Medicare University Nitroglycerin Pulse Pro-re-nata, as needed Respirations Shortness of breath Temperature 6 National Government Services, Inc.

7 Objectives Understand the documentation needed to support the nursing visits provided 7 National Government Services, Inc.

8 Agenda Coverage guidelines Documentation examples 8 National Government Services, Inc.

9 Skilled Nursing Requires skills of a registered nurse Necessary to treat illness Complexity 9 National Government Services, Inc.

10 Skilled Nursing Intermittent Skilled nursing care that is either provided or needed on fewer than seven days each week or less than eight hours of each day for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional care is finite and predictable) Recurring need Not just a one-time visit 10 National Government Services, Inc.

11 Observation and Assessment When the patient s condition is changeable Until condition stabilizes Not routine monitoring 11 National Government Services, Inc.

12 Observation & Assessment Patient admitted to home health 7/31/12 following an acute anterolateral myocardial infarction with stent placement. Plan to visit twice a week for three weeks. Three PRN visits for worsening symptoms Reviewed medication regimen and spouse set up medication set correctly. 12 National Government Services, Inc.

13 Observation & Assessment Admission assessment: Alert and oriented x3, T-98.2 P-84 and regular, R-18 BP-136/82 Breath sounds clear. Oxygen saturation 94% on room air. Denies chest pain. States she only has shortness of breath on exertion. Becomes short of breath when walking from bedroom to kitchen. Abdomen soft with bowel sounds all quadrants. Slight bilateral pedal edema. 13 National Government Services, Inc.

14 Observation & Assessment 8/2/2012 Alert and oriented. Had an episode of chest tightness last evening. She took a NTG tablet and it relieved the tightness within 5 minutes. No other symptoms occurred with this episode. 14 National Government Services, Inc.

15 Observation & Assessment T 97.6 P 84 regular R 18 BP 142/68. Breath sounds clear. Minimal nonproductive cough. Slight increase in pedal edema from initial visit. Reviewed correct use of NTG. Reviewed side effects. Patient able to explain correct treatment of chest pain and side effects of NTG. 15 National Government Services, Inc.

16 Observation & Assessment 8/6/ :00 AM Alert but disoriented to time and place. Thinks it is 1999 and she is at Sue s house. Spouse explained last evening she was slightly confused but is worse today. Last night she was not making sense. 16 National Government Services, Inc.

17 Observation & Assessment T 98.4 P 88 Regular R 20 BP 134/78. She has been taking her medications as prescribed but has been eating poorly-mostly just soup. Breath sounds clear with no cough. Slight bilateral pedal edema. Pupils equal and reactive. Denies headache. Smile even. Arms strong and equal. Leg strength equal. Call to Dr. Smith and report given. Stat labs ordered. Venipuncture done and CBC, chemistry profile drawn and taken to lab. 17 National Government Services, Inc.

18 Observation & Assessment 8/6/2012 3:30 PM Dr. Smith called. Electrolytes are low and he thinks this is probably the cause of the confusion. Order for 2 extra doses of Potassium supplement today and tomorrow. Double dose of potassium starting 8/8. Magnesium supplement ordered to start today and he called in to pharmacy. Extra nursing visit tomorrow to assess patient. 18 National Government Services, Inc.

19 Observation & Assessment Phone call to patient s husband. Instructed him to give his wife an additional potassium tablet now and another at 9:00 PM. He will pick up the new prescription and have his wife take it today. 19 National Government Services, Inc.

20 Observation & Assessment 8/7/12 Alert and oriented today. Speech is clear and appropriate. T 98.4 P 78 Regular R 16 BP 135/78 Oxygen saturation 97%. Breath sounds clear. No chest pain or shortness of breath. Took the 2 extra doses of potassium and 1 dose of Magnesium yesterday. States will take additional doses of potassium and magnesium today. Magnesium added to med set for the week. No nausea or abdominal pain. 20 National Government Services, Inc.

21 Observation & Assessment Ate an egg and a piece of toast today with a banana for breakfast. Instructed patient and spouse about need for adequate nutrients. Advised caregiver to monitor nutritional intake. 21 National Government Services, Inc.

22 Observation & Assessment 8/9/12 Alert and oriented. Has not experienced any additional periods of confusion or disorientation. T 97.6 P 84 regular, R 18 easy. BP 142/82. Oxygen saturation 95%. No additional chest tightness. Denies nausea, vomiting and shortness of breath. Breath sounds clear. Slight pedal edema bilaterally. Spouse states she has been eating more the last 2 days than she had last week. For breakfast she had yogurt, orange juice and a banana. 22 National Government Services, Inc.

23 Observation & Assessment Reviewed dietary restrictions of a low fat diet. Spouse and patient verbalize understanding and were able to select low fat items from a list. 23 National Government Services, Inc.

24 Observation & Assessment 8/13/12 Alert and oriented. No confusion experienced since my last visit. T 98.2, P 68 regular R 18 BP 140/72. Breath sounds clear. States she has a bit more energy. Walked outside about 100 feet with her spouse before becoming tired. Encouraged to gradually do a little more each day. Has not had any chest tightness, nausea, vomiting, neck or jaw pain. Slight bilateral pedal edema unchanged. 24 National Government Services, Inc.

25 Observation & Assessment Dietary intake has been adequate according to patient and spouse. Ate a banana, oatmeal, and orange juice for breakfast. Reviewed signs/symptoms of myocardial infarction and actions to take. Able to describe symptoms and to call 911 if they occur. Able to explain her medications and set up her medication reminder. Plan discharge at next visit. 25 National Government Services, Inc.

26 Observation & Assessment 8/16/2012 Remains alert and oriented. T 97.8 P 74 regular R 16 BP 136/74. Oxygen saturation 94%. Denies any chest pain or shortness of breath. Breath sounds clear. No cough. Minimal bilateral pedal edema. Abdomen soft with active bowel sounds. Ambulates ~150 feet before becomes fatigued. Is gradually increasing activity. 26 National Government Services, Inc.

27 Observation & Assessment Able to complete her ADL independently but still needs help with IADL. Feels comfortable with knowledge of her disease and medications. Discharged. 27 National Government Services, Inc.

28 Observation & Assessment Patient discharged from hospital with CHF. Plan to visit 2 times a week for 3 weeks 2/7/12 Admission assessment: BP 148/74, P 86 and regular, R 22, Oxygen saturation 94% room air, weight 156 pounds, breath sounds clear bilaterally, intermittent cough-productive of clear mucous, 2+ non-pitting pedal edema. Feels tired, denies SOB. Reviewed medication regimen and verbalized understanding. N. Nurse RN 28 National Government Services, Inc.

29 Observation & Assessment 2/10/12 BP 152/92 P 98 regular R 24 Oxygen saturation 92%, breath sounds rales in bases, coughing more than last visit-nonproductive, 1+ pedal edema. Slight SOB. Feels tired-not sleeping well due to cough and sleeping in chair. Called Dr. Smith. Additional furosemide 40 mg orally ordered for today and increase dose to 40 mg daily. Patient and daughter notified. N.Nurse RN 29 National Government Services, Inc.

30 Observation & Assessment 2/14/12 BP 136/80 P 80-regular R 20 Oxygen saturation 95%, breath sounds clear, coughing intermittently-non-productive, 2+ pedal edema, feels better, no SOB yesterday or today since furosemide dosage was increased. N. Nurse RN 30 National Government Services, Inc.

31 Observation & Assessment 2/17/12-BP 126/78, P 80 regular, R 18, breath sounds remain clear. Oxygen saturation 94%, weight 155, States she is coughing less and now able to sleep in bed with an extra pillow. She is sleeping better now. 1+ pedal edema. She filled her medication set correctly. N. Nurse RN 31 National Government Services, Inc.

32 Observation & Assessment 2/20/12 BP 132/80 P 82 R 18 Oxygen saturation 96% on room air. Coughing occasionally-much less than prior visits. Minimal edema. States her breathing is good. Breath sounds clear. Call to Dr. Smith. Discharge from home care today. N. Nurse RN 32 National Government Services, Inc.

33 Central Line Care Nursing visits to flush a port in place for future medication administration can be necessary but the plan has to be documented. 33 National Government Services, Inc.

34 Central Line Care 7/16/12 Calm, slight SOB on exertion, Oxygen at 2 liters/minute per nasal cannula at night and as needed during the day. Breath sounds clear bilaterally. T 97.0 P 66 R 18 BP 134/76. Port-a-cath present in left chest. Dressing is dry and intact. No swelling present. Port flushed with saline and heparin. Plan to use port in September for next round of chemotherapy administration. 34 National Government Services, Inc.

35 Central Line Care Home health services only to have a nurse draw blood from a port due to poor venous access would not be covered. 35 National Government Services, Inc.

36 Medication Administration Dosage and frequency must be appropriate for the patient s medical condition Documentation must include documentation that the patient has the condition Vitamin B 12 injections are covered for specific diagnoses Publication , Chapter 7, Section National Government Services, Inc.

37 Medication Administration Homebound patient with long standing pernicious anemia receiving home care services for monthly injection. Now also has had other medical issues diagnosed. Records must include information regarding the pernicious anemia to support the visits where the skilled service provided was the B12 injection. 37 National Government Services, Inc.

38 Medication Administration 7/1/2012 Vitamin B mcg IM left deltoid for pernicious anemia. 8/1/2012 Vitamin B mcg IM right deltoid for pernicious anemia. 38 National Government Services, Inc.

39 Suprapubic Catheter Care 1/10/12 Recertification. Patient with history of multiple sclerosis resulting in paralysis. Bedbound. Long term use of suprapubic catheter. Requires catheter change every days and prn visits for symptoms of urinary tract infection or other problems. T 98.4 P 72 R 18 BP 138/76 suprapubic catheter changed with 18 French catheter with 5 cc balloon. Urine is clear amber. 39 National Government Services, Inc.

40 Suprapubic Catheter Care 1/31/2012 Caregiver called because the patient feels sick and is having chills. T P 78 R 16 BP 132/76. Urine is very cloudy with sediment. Dr. Jones contacted. Urinalysis and culture ordered. Specimen collected and taken to lab. Instructed to drink extra fluids. Instructed caregiver that acetaminophen can be taken for elevated temperature. 40 National Government Services, Inc.

41 Suprapubic Catheter Care 1/31 Dr. Jones called with urinalysis resultsbacteria present. Prescription called into pharmacy. Call to caregiver and notified of this. He will pick it up and have patient begin medication tonight. Extra visit on 2/2 ordered. 2/2/12 -T 98.2 P 78 R 18 BP 134/72 Taking antibiotics as ordered. Urine is clear amber. Feels better now. No longer chilled. 41 National Government Services, Inc.

42 Suprapubic Catheter Care 2/13/12 T P 72 R 16 BP 128/60 Suprapubic catheter changed with a 18 French catheter with a 5 cc balloon. Urine is clear amber without sediment. Skin warm and dry. Instructed caregiver about correct catheter care and demonstrated correct technique. 42 National Government Services, Inc.

43 Wound Care 6/1/12 Right lower leg 4.0 x 3.4 x 1.7 cm. Wound bed has yellow slough, moderate amount, foul-smelling yellow drainage. Pain level 5/10. Taught wound care to daughter who is caregiver. Demonstrated ability to do wound care. Daughter to do wound care 5 days. Will visit twice a week to assess and do wound care. N. Nurse RN 43 National Government Services, Inc.

44 Wound Care 6/4/12 Right lower leg moderate yellow drainage. Wound bed has small amount pink and rest yellow slough. Wound care per plan of care. Daughter expresses no concern with performing wound care. Pain level 5/10. N. Nurse RN 44 National Government Services, Inc.

45 Wound Care 6/8/12 Right lower leg 3.6 x 3.0 x 1.0 cm. Wound bed is 1/3 pink, 2/3 yellow slough with moderate drainage. Pain 4/10. Dressing per plan of care. N. Nurse RN 6/12/12 Right lower leg wound is 2/3 pink, 1/3 yellow with minimum drainage. Pain 4/10. Dressing per plan of care. N. Nurse RN 45 National Government Services, Inc.

46 Wound Care 6/15/12 Right lower leg 3.3 x 2.5 x 0.5 cm Minimal yellow drainage. Wound bed ¼ yellow, ¾ pink. Pain 3/10. Dressing per plan of care. N. Nurse RN 6/19/12 Right lower leg. Minimal light yellow drainage. Wound bed ¾ pink, ¼ yellow. Pain 4/10. Dressing per plan of care. N. Nurse RN 46 National Government Services, Inc.

47 Wound Care 6/22/12 Right lower leg 2.8 x 2.0 x 0.3 cm. Wound bed is pink. Minimal clear drainage. Pain is 2/10. Dr. Jones notified of improvement. Wound care orders updated. Dressing changed. Daughter instructed on updated wound care. Verbalized understanding. Plan discharge next visit. N. Nurse RN 47 National Government Services, Inc.

48 Wound Care 6/26/12 Right lower leg 1.9 x 1.0 x 0.2 cm. Wound bed pink with no drainage. Wound continues to heal. No pain. Dressing applied. Daughter independent with wound care at this time. Discharged from home care. N. Nurse RN 48 National Government Services, Inc.

49 Teaching Management of a new treatment regimen Self-injection of medication Care for a new ostomy Self-catheterization Wound care Care of intravenous line 49 National Government Services, Inc.

50 Teaching Diabetes not controlled with diet and maximum oral hypo-glycemics. Starting on insulin coverage. 2/1/12 Client demonstrated ability to correctly test blood using his monitor. Instructed on determining amount of insulin needed depending on blood test. Demonstrated drawing up insulin. Client able to demonstrate same with cues. S. Smith RN 50 National Government Services, Inc.

51 Teaching 2/2/12 Instructed client to use dart-like motion for injection. Client able to do finger stick blood sugar, determine correct dose and draw up and administer injection with cues. Reviewed signs/symptoms of hypoglycemia and actions to treat. N. Nurse RN 51 National Government Services, Inc.

52 Teaching 2/3/12 Explained need for rotation of injection sites with client and provided diagram. Client able to state reason sites must be rotated and which areas are acceptable for injection. Finger stick blood glucose done correctly. Drew up insulin and injected into abdomen correctly without cues. States feels is able to do this independently now. S. Smith RN 52 National Government Services, Inc.

53 Teaching 2/6/12 Instructed regarding need for foot care due to diabetes including: Observe feet daily for any sores, discoloration, or other problems Wash and apply lotion to keep skin moisturized Protect feet from injury as injuries often are slow to heal due to high glucose level/poor circulation Visit podiatrist to have toe nails trimmed 53 National Government Services, Inc.

54 Teaching 2/9/12 Reviewed foot care instructions with patient and spouse. Able to demonstrate assessment of his feet. Verbalized need to visit a podiatrist for trimming his toe nails. He has a visit with his podiatrist scheduled for 3/1. 54 National Government Services, Inc.

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60 Medicare University Self-Reporting Instructions Log on to the National Government Services Medicare University site at Topic = Improve Your Home Health Nursing Documentation Medicare University Credits (MUCs) = 1 Catalog Number = To be provided Course Code = To be provided For step-by-step instructions on self-reporting please visit > Medicare University > Accessing the Self-Reporting Tool 60 National Government Services, Inc.

61 Thank You! 61 National Government Services, Inc.