Form Design. Clinical Documentation System for Hospice. Melanie Merriman, PhD, MBA. Medicare CoPs. LCD guidelines. Care process/ flow

Transcription

1 Clinical Documentation System for Hospice Melanie Merriman, PhD, MBA Weatherbee Resources, Inc. Hospice Education Network, Inc. Hospice Quality Resources, LLC. Medicare CoPs Form Design LCD guidelines Care process/ flow Initial Assessment Diagnosis and chief complaints Vitals & symptom assessment Brief psychosocial assessment Brief spiritual assessment Brief environmental assessment Comprehensive Assessment Nursing assessment May include any/all of the following Psychosocial assessment Spiritual assessment Other assessments (e.g., PT, OT, ST, Dietician) QAPI data elements Drug Profile & Drug Profile Review Hospice Assessment and Care Planning Clinical Notes All disciplines Assessment Updates At least every 15 d Nursing update May include any/all of the following Psychosocial update Spiritual update Other updates (e.g., PT, OT, ST, Dietician) Plan of Care UPDATES May include Drug Profile Review At least every 15 d QAPI data elements QAPI data elements QAPI Measures Care processes Patient outcomes Progress toward goals 2008 Weatherbee Resources, Inc.

2 Types of Documentation Forms Consent, Election, Certification and Recertification Assessments Determining Terminal Status Worksheets based on LCD guidelines Hospice Plan of Care Drug Profile Assessment Updates Clinical and Progress Notes Other Consent, Election, Certification and Recertification Statement of Consent and Election Attending Physician Initial Certification of Terminal Illness Hospice Physician Initial Certification of Terminal Illness Hospice Physician Recertification of Terminal Illness Medicare Hospice Revocation Form Assessments Comprehensive Hospice Assessment Cover Page Initial & Comprehensive Nursing Assessment Fall Risk Assessment Physical Pain Assessment Skin Impairment Assessment Safety Assessment Bereavement Risk Assessment Comprehensive Psychosocial Assessment Financial Assessment Comprehensive Spiritual Assessment

3 Determining Terminal Status Worksheets Document patient s signs and symptoms of terminal illness based on Local Coverage Determination (LCD) guidelines developed by fiscal intermediaries for Medicare Decline in Clinical Status Worksheet patients with no specific diagnosis Patients with specific diagnoses Adult Failure to Thrive Worksheet Renal Disease Worksheet ALS Worksheet Cancer Worksheet Dementia Worksheet Heart Disease Worksheet HIV Worksheet Liver Disease Worksheet Pulmonary Disease Worksheet Stroke and Coma Worksheet Completed in consultation with attending physician and/or hospice physician Hospice Plan of Care Hospice Plan of Care Hospice Aide Plan of Care Hospice Aide Flow Sheet Hospice Plan of Care Change IDG Review & Update to the Hospice Plan of Care Bereavement Plan of Care Drug Profile Drug Profile Drug Profile Cover Page Drug Profile Review All medications Rx, OTC, Herbal, Alternative/ Complimentary

4 Assessment Updates Nursing Assessment Update Psychosocial Assessment Update Spiritual Assessment Update Clinical and Progress Notes Nursing Clinical Note (Visit documentation) Progress Note (Non-visit documentation all disciplines) Pyschosocial/Spiritual Clinical Note (Visit dcoumentation) Volunteer Note (Visit documentation) Other/Miscellaneous Care Coordination Sheet for non-hospice providers Hospice Longitudinal Data Assessment Tool (LDAT) LDAT Quick Reference Guide Physicians Orders and Medication Record (applies to hospice-owned inpatient settings only)

5 Assessments and Assessment Updates Include data elements for outcome measurement Compliance with QAPI and other CoPs Shaded for ease of retrieval Reference sheets to facilitate systematic data collection Hospice policy Whether assessments can be completed by phone Required signatures Documentation on updates if information has not changed All Forms Upper left Name of form (use for reorder) Upper right Hospice Certification Number Blank Line Name of hospice Name of location Lower left Form number Lower right Page number All Visit Notes Assessments Assessment Updates Clinical Notes Type of visit In-person Phone Other Other visit information Time in/out Scheduled/unscheduled Signatures Hospice staff Pt/Fam or Facility Staff

6 Care Plans and Updates Individualized Signatures of all IDG members involved in planning and care delivery Indication of discussion with patient, family, attending physician (if there is one) Information on outcomes of care (QAPI) For more information Contact Elaine Reilly at Weatherbee Resources, Inc To order Order online at Call