documentation and scales - transitions...

DOCUMENTATION

AND SCALES

• Documentation should include:

• Clinical findings describing vital signs, weight

loss/gain, fevers, wound status, etc…

• Interventions provided and the response of the

beneficiary and family.

• Teaching, communication and collaboration with

facility and POA/Family.

• The course of the terminal illness.

• Interventions that are consistent with the plan of care.

ROUTINE DOCUMENTATION

• POOR DOCUMENTATION

• Diagnosis of dementia. Weight is 100 lbs. Poor

appetite. Sleeps a lot. Has had past infections.

• GOOD DOCUMENTATION

• Hospice Diagnosis is Dementia, KPS: 40, FAST:

7D from 7A, PPS: 40%, Unable to make needs

known and speech is nonsensical. Incontinent

of bowel and bladder, cannot ambulate, and

remains bed/chair bound. Weight loss of 15 lbs

in the last 2 months, remains on honey

thickened liquids and needs total assist with

feeding and all other ADLS. Appetite is now

poor. Three UTI’s treated in last 6 months

1. ROUTINE VISIT DOCUMENTATION

• ROUTINE VISIT

• Has poor appetite: eating 3-4 bites of food with

difficulty as evidenced by pocketing of food.

Eating an avg. of 25-50% of meals, drinks 2-3

sips of liquids coughing noted.

• Current weight of 100 lbs, weight loss of 15 lbs

in 2 months. BMI 19.5 (May weight 115 lbs,

June 106 lbs)

• April 2013 hospitalized for pneumonia and

treated with IV Antibiotics.

2. ROUTINE SUPPORTIVE DOCUMENTATION

• Make sure spelling of all terms is accurate.

• When checking boxes, make certain they are

accurate.

• Chart visit immediately if possible.

• Document the patient/caregiver/family’s response

to teaching and other interventions.

• Only use authorized abbreviations.

ELEMENTS OF EFFECTIVE

DOCUMENTATION

• Infections within the past 12 months.

• Details of medication(dosage, route, frequency),

and the patients response.

• Refusals of treatment, medication, therapy, etc…

Document refusals to physician and all

appropriate disciplines .

• Good to include repeating past observations that

were evident of the patient’s decline (i.e. recent

hospitalizations, decreased tolerance to ADLs,

etc).

GENERAL DOCUMENTATION

REQUIREMENTS

• ANYTIME ONE USES DESCRIPTORS SUCH

AS:

• Cachectic, anorexic, non-ambulatory, dyspnea (at rest or

on exertion), weight loss, poor appetite, fragile, agitated,

weaker etc…

• Always follow up with “as evidenced by…” to fully

describe what is seen:

Example: “Patient appears tachypnic as evidenced

by respiratory rate of 32 and use of accessory

muscles.”

GENERAL DOCUMENTATION

REQUIREMENTS – “AS EVIDENCED BY”

HOSPICE

• Focus on what patient

cannot achieve

• Palliative treatment

• Documentation

reflects a negative

outcome.

DOCUMENTATION FOCUS

HOSPITAL

• Focus on what

patient can achieve

• Curative treatment

• Documentation

reflects a positive

outcome

SHIFT YOUR FOCUS FROM

CURATIVE TO PALLIATIVE.

• RN/LPN - CARE PLAN PROBLEMS

• Care plans need to be reviewed weekly.

• Related care plans should also be changed,

updated and notes added when there is a

change in the patient’s condition. (For example

when a patient is diagnosed with a UTI, the care

plan should be updated with a note entered).

• When the issue has resolved the care plan

should be resolved. Only care plans that should

be open are ongoing issues.

DOCUMENTATION REQUIREMENTS

• RN/LPN - MEDICATIONS

• Medications need to be up to date and match

the facility POS. Make sure to enter new

medications and discontinue old medications at

each visit.

• Entering Meds:

• Include: Dose, Route, Frequency and

PURPOSE

• EXAMPLE: Albuterol 1 vial neb q 4hrs PRN

for periodic SOB. – What’s it treating?


• 24/48 hour admit follow up visits

• All pts need a 24-48 hour admit follow up done.

Most are done by the next day.

• If a pts is admitted with pain, the admitting nurse

will make note of this in the quality measure tab.

On these pts there must be a 24 and 48 hour

follow up visit. The 24 hour follow up visit is just

a standard routine visit with clinical note. The 48

hour follow up is a routine visit, clinical note

AND you must go into the quality measures tab

and fill out the 48 hour assessment.


• ROUTINE ASSESSMENT

• Record weights, infections, falls, etc

• Make sure to enter weights under clinical

monitoring monthly. All infections and falls

should be under their tab and end infections

when they are no longer relevant.

• In each section throughout the assessment

make sure you are clicking on appropriate

boxes. If there is any change in pts baseline,

there is a box in each section to elaborate on

this.


REQUIREMENTS

• ROUTINE ASSESSMENT

• SKIN

• Measurements must be done weekly by

Hospice RN.

• Coordinate with the wound care nurse to be

able to view the wounds

• Follow the wound care protocols.


REQUIREMENTS

• Visit frequencies are to be determined by

admission nurse.

• Visit frequencies: Aides-if they have a

care giver or they don’t need/benefit a

spa/social visit, 3 aide visits a week may

not be appropriate.

• Any visit frequency changes need to be

discussed with RNC or DOCO. Make

sure to update the visit frequencies in

Allscripts and make sure the aide

schedule reflects the correct amount.

VISIT FREQUENCIES

• Must be order upon admission, or at eval if

necessary.

• Must be checked at 24 hours follow-up after

admission.

• Must be checked weekly and documented in

routine visit.

• Record expiration date in care plan, make sure

you are ordering refill before med expires.

• If pt starts showing decline, or when medication is

first used from comfort kit, refills should be

ordered.

COMFORT KITS

• Appropriate documentation of scales:

• PPS: Palliative Performance Scale. Pick the

best fit option. To be a 30% the patient must

require total assistance with ALL ADLs. The

PPS scale is a measure of what the patient

would be able to do, not on what they refuse to

do.

• A patient that is able to feed self finger food, roll

over in bed, or pivot with an assisted transfer

would not be considered a PPS of 30%

DOCUMENTATION OF SCALES


• KPS: Karnofsky Performance Status Scale

measures the patients functional impairments

and can assess their prognosis.

• A KPS of 40 would be a total assistance with all

ADLs. A patient living at home alone without a

24 hour care giver would not be a 40 or less.

• A KPS of 50 would be a patient that is unable to

work but able to live at home and care for most

personal needs with considerable assistance

and frequent medical care.



• FAST: Functional Assessment Staging of

Alzheimer’s Disease. Can only be used if

patient has a diagnosis of Dementia. A FAST

score of 7C means the patient meets the criteria

of ALL the previous stages.

• For example, a patient that has lost their ability

to ambulate would ONLY be considered a 7C if

they also were incontinent of bowel and bladder,

Speech ability limited to the use of a single

intelligible word and requires assistance with

ADLS.


• Communication with team, working together with

SW, Aide, RNC, Chaplain, etc.

• ADP, questions and review.

MISC

• BERRY, R. (2010). Understanding and

Documenting the General Inpatient Care Level of

Care [PowerPoint slides]. Retrieved from R&C

Healthcare Solutions;

http://www.rchealthcaresolutions.com/.

• Center for Medicaid Services - http://www.cms.gov

• CMS Benefit Policy Manual -

http://www.cms.gov/manuals/Downloads/bp102c1

5.pdf

• NHCPO-

http://www.nhpco.org/templates/1/homepage.cfm

SOURCES

Please contact Transitions if you have any questions

about of the advance directives discussed today.

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documentation and scales - transitions...

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