Check out these eight tips for better documentation
Home health standards expert gives advice
The next time you prepare for an accreditation survey or decide to speak with staff about documentation, you may want to clip these handy guidelines about how everyone may improve documentation.
"People do the care, but sometimes they don’t document," says Tina Marrelli, MSN, MA, RNC, president of Marrelli & Associates in Boca Grande, FL. Marrelli is the author of the popular home care guide Handbook of Home Health Standards and Documentation Guidelines for Reimbursement, published by Mosby-Year Book Inc. of St. Louis in 1988. The third edition was published in 1998.
However, it’s more important than ever in today’s home care environment that nurses understand the importance of documentation, Marrelli says. "And maybe documentation hasn’t been given the emphasis it needs."
This way to better documentation
Marrelli offers these eight simple guidelines to better documentation:
1. Educate staff on documentation.
"Documentation is an ongoing concern in all health care settings; but particularly in home care, education is the key," Marrelli explains. "And maybe some of us weren’t taught documentation when we were hired, or maybe we didn’t learn it at the last job."
Home care quality managers should make sure their staffs are taught about documentation when first hired, and they should review documentation annually in an inservice, she advises.
2. Remind staff that clinical records are important.
"Make sure their writing is legible and that everyone documents what they did," Marrelli says.
For example, if a nurse gives an injection, or wound care, the nurse should observe the patient’s response and document that.
"What was the patient’s response to our care intervention and what sort of analysis did we do?" she asks. "Look at all the assessed information and care provided and ask, How does that change the plan?’"
Then, the nurse should document whether the doctor was called and updated, and whether the agency needs to change the projected timeline for the patient, maybe discharging the patient earlier or providing more care and why, Marrelli adds.
3. Tell story through documentation.
The nurse’s notes and the record documentation tell the patient’s story from admission through discharge. Everyone involved in the documentation should make sure the story is complete.
"Make sure anyone reading that nursing note knows what’s going on with the patient, including the specific wound care provided, and whether it was a sterile or non-sterile technique," Marrelli says. "This is so the patient receives the same level of care, regardless of who the provider is and everyone is literally on the same page."
4. Focus on identified problems.
Home care staff should change its mindset from that of working with potential problems to a mindset of focusing on identified problems, she suggests.
"The classic example is a patient who has congestive heart failure (CHF) and diabetes," Marrelli says. "But if the patient’s diabetes management is stable, then we’re in there to focus on CHF and getting those medications regulated or whatever the problem is that got us involved in the care."
In home care’s good old days when agencies were reimbursed based on costs, a home care nurse might have had the luxury to also reinforce the CHF patient’s diabetes education. But those days are gone under the interim payment system (IPS), and agencies have shorter time frames to provide patients the care they need, so they need to focus on the identified problems, she explains.
5. Patient education is the key.
The new documentation environment calls for formal patient education. "This means, for example, the development of standardized patient education tools to make sure that all nurses are teaching from the same sources," Marrelli says.
The patient education sources should be reviewed by clinical specialists or be nationally accepted standards of practice, such as the standards developed by the Agency for Health Care Policy and Research in Rockville, MD.
The AHCPR has a national mandate from Congress to develop clinical practice guidelines for physicians, hospitals, and other health care providers.
6. Use clinical pathways.
"We’re going to see an increased use of clinical pathways because it makes sense," Marrelli says. "It’s a good way to standardize the care provided to a patient because we admit the patient in the same order, explain care in the same way."
One of the best features of clinical pathways is that the best standards of practice are already incorporated into them.
Or agencies can use other standardized care protocols that help support sufficient completion of documentation and cue interventions based on best practices.
7. Continually review documentation systems.
Look at your whole documentation system, including checklist tools and how the assessment form drives the care plan, Marrelli advises.
"If you just have a big narrative hole in your documentation form, then it’s really hard for a nurse to think of what to write and what to leave out," she adds. "A lot of the best tools are a blend of narrative and checklist, and maybe even backed up with a glossary of what things mean at a given organization."
For example, a wound category could be referenced within a home care agency so that all nurses and physicians use the same terminology describing the wound and its treatment.
Everyone should be using documentation forms in the same way, whether these are the visit forms, care coordination forms, or any other type.
"Give clinicians a completed sample form as part of orientation or when there’s an update to show them what this form should look like when it’s completed," Marrelli says. "The form should be supporting care coordination so that anybody following up on care really has a picture painted of what happened to that patient."
8. Standardize care practices and documentation.
"As we move to a more outcomes-oriented environment, the only way we’re going to get there is through standardization of care practices and documentation," Marrelli states.
"If the ingredients to get there aren’t the same, there’s no way to standardize comparisons," she adds.
Some home care agencies, for instance, will have a nurse follow up another nurse who has completed an OASIS assessment form by filling it out the same way. This way, the organization can make sure the form’s documentation is standardized.
Also, a manager might validate the documentation on an OASIS tool as part of a standard performance improvement process. Quality managers could conduct random sample reviews of OASIS forms to make sure they are completed correctly and uniformly.
This focus on standardization should include all assessment tools, including pain management tools, Marrelli adds.
Standardization, along with these other guidelines, will help home care agencies protect themselves during payer or Medicare audits.
"There’s no question that home care documentation continues to be under the spotlight," Marrelli says. "The government’s initiatives like Operation Restore Trust are looking for ways to save money, and unfortunately, they’ve been successful in home care; our documentation can either help protect us, or maybe not."
Source
• Tina Marrelli, MSN, MA, RNC, President, Marrelli & Associates, P.O. Box 391, Boca Grande, FL 33921. Telephone: (941) 697-2900. Fax: (941) 697-2901.
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