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HIS - Shortness of Breath in an unresponsive patient

Posted
by AriRN36 AriRN36 (New) New Nurse

Has <1 years experience.

Hi all,

I just started at a new hospice and don't agree with the way they want me to fill out the Hospice Item Set questions about Shortness of Breath.

For those who use Netsmart/McKesson, this focuses on the Respiratory assessment and HIS J2030A.

Situation: I admitted a GIP patient onto hospice services yesterday for metabolic encephalopathy. He has no history of O2 use, but was currently on O2 for comfort when I arrived. My preceptor told me to mark the box for "shortness of breath" and "shortness of breath while talking or eating or performing other ADLs" because it is ASSUMED that he would have SOB while performing those tasks. She also stated that if I were to click the "None" box, that would have a negative impact on our HIS scores.

In my opinion, an assessment is what I know and see, and I don't know that he is SOB. His respirations were WNL and were not labored.

Would you chart SOB or not?

Thanks!

cardiacfreak, ADN

Specializes in Hospice.

Nope, I chart what I see and what family and/or patient tell me.

heron, ASN, RN

Specializes in Hospice. Has 40 years experience.

On 6/17/2020 at 8:36 AM, AriRN36 said:

Hi all,

I just started at a new hospice and don't agree with the way they want me to fill out the Hospice Item Set questions about Shortness of Breath.

For those who use Netsmart/McKesson, this focuses on the Respiratory assessment and HIS J2030A.

Situation: I admitted a GIP patient onto hospice services yesterday for metabolic encephalopathy. He has no history of O2 use, but was currently on O2 for comfort when I arrived. My preceptor told me to mark the box for "shortness of breath" and "shortness of breath while talking or eating or performing other ADLs" because it is ASSUMED that he would have SOB while performing those tasks. She also stated that if I were to click the "None" box, that would have a negative impact on our HIS scores.

In my opinion, an assessment is what I know and see, and I don't know that he is SOB. His respirations were WNL and were not labored.

Would you chart SOB or not?

Thanks!

My first thought, albeit possibly unfair, is to wonder whether staff are being asked to “buff the chart” in order to justify GIP status.

GIP carries the highest reimbursement rate in hospice. When I worked hospice, we were told we were no longer allowed to claim caregiver breakdown or terminal care as reasons for GIP due to the number of fraudulently padded claims using those dx.

A fine line to walk. Be careful!

heron, ASN, RN

Specializes in Hospice. Has 40 years experience.

14 minutes ago, Susie2310 said:

What is GIP?

General inpatient. It is the reimbursement level for hospice patients who require 24-hour inpatient care.

21 minutes ago, heron said:

General inpatient. It is the reimbursement level for hospice patients who require 24-hour inpatient care.

Thank you for explaining.

AriRN36

Has <1 years experience.

On 6/22/2020 at 2:42 AM, heron said:

My first thought, albeit possibly unfair, is to wonder whether staff are being asked to “buff the chart” in order to justify GIP status.

I'm a skeptical person, and I truly don't think that's the reason she wanted me to chart that way. So - assuming that was not the reason - what's your opinion? Does it make sense/not make sense to chart an assumed SOB? Thanks

heron, ASN, RN

Specializes in Hospice. Has 40 years experience.

22 minutes ago, AriRN36 said:

I'm a skeptical person, and I truly don't think that's the reason she wanted me to chart that way. So - assuming that was not the reason - what's your opinion? Does it make sense/not make sense to chart an assumed SOB? Thanks

It doesn’t make sense to me. If resps are even and unlabored and pulse ox is up, there’s no reason to find SOB. I view charting a symptom that “would be there if the pt was awake” as quite dicey. Verging on false documentation.

I still say be verrry careful.