New Charting Regs?

nutella, MSN, RN · Jun 6, 2016

At my previous place of employment we were instructed we could no longer use the shorter PRN form for PRN or second/third routine scheduled visits starting about October or November last year. We were told that this was due to changes in Medicare requirements. I have started at a new hospice last week and they are still using the short forms for PRN and LVN(focused assessments). I am struggling to find any sort of information online on this topic.
Has anyone else run up against this in the last 6 months or so? And if so, do you know how/where I would find some for-reals confirmation?

I am not sure what you refer to with "short form" - do you mean a shorter form of assessment? I have used the same assessment for all hospice patients. The only difference was the longer narrative in the initial admission note. Also, there are certain data that need to be collected nowadays for hospice and submitted. Personally, I think every patient who gets a hospice visit needs a comprehensive assessment as the whole goal is symptom management.

simbawicz · Jun 18, 2016

I am not sure what you refer to with "short form" - do you mean a shorter form of assessment? I have used the same assessment for all hospice patients. The only difference was the longer narrative in the initial admission note. Also, there are certain data that need to be collected nowadays for hospice and submitted. Personally, I think every patient who gets a hospice visit needs a comprehensive assessment as the whole goal is symptom management.

We have comprehensive visit documentation with supervision questions that are expected with each weekly visit, and are done by an RN minimally every 14 days. We have nursing visits minus supervision that can be done by an RN or LPN. We have PRN visits that are "focus" visits. So, if I typically see a patient weekly, and for example I fully assess a patient on Monday, see something new, or make a med change, and want to check back in in 24-48 hours, I will choose the PRN visit. I will focus on that thing I am rechecking, still assess the patient as usual, but only need to document the area of concern, and of course any further decline, new symptom, etc. In all visits we also document a narrative even though the visit notes are pretty thorough. The PRN visits are acceptable as long as we do the comprehensive visits within the 14 days. I believe it is actually 15 days, but our company policy is 14, and a little easier to track, I think. I am an RN Case Manager, and this has been the documentation expectation in 2 companies in 2 different states. Does that help?

nutella, MSN, RN · Jun 18, 2016

Charting is driven by a variety of things and includes regulations and requirements around reimbursement as well.

If your agency uses one of the usual charting software, I would assume that they are updating it accordingly when the requirements change.

CMS requires the documentation of certain metrics and data collection, which means that the commercial softwares got updated to include all the required data. I guess it is only a matter of time until there will be an OASIS for hospice admissions and recerts.

I used Cerner Roadnotes in hospice and their "forms" are very comprehensive but also a lot of checklists, making it easier.

I think if you just re-visit and target a specific problem or education, your documentation will reflect that. But you have to do a full assessment each time you see a patient in hospice and address the most important things:

-pain

-respiration

-bowels (!)

-N/V

- mental state

-decline in status?

-teaching (!)

-medication review

In addition, a narrative that helps to "paint the picture" is important.

simbawicz · Jun 18, 2016

Charting is driven by a variety of things and includes regulations and requirements around reimbursement as well.
If your agency uses one of the usual charting software, I would assume that they are updating it accordingly when the requirements change.
CMS requires the documentation of certain metrics and data collection, which means that the commercial softwares got updated to include all the required data. I guess it is only a matter of time until there will be an OASIS for hospice admissions and recerts.
I used Cerner Roadnotes in hospice and their "forms" are very comprehensive but also a lot of checklists, making it easier.
I think if you just re-visit and target a specific problem or education, your documentation will reflect that. But you have to do a full assessment each time you see a patient in hospice and address the most important things:
-pain
-respiration
-bowels (!)
-N/V
- mental state
-decline in status?
-teaching (!)
-medication review
In addition, a narrative that helps to "paint the picture" is important.

Exactly what she said. :yes:

I use Home Care Home Base.

nutella, MSN, RN · Jun 18, 2016

Exactly what she said.
I use Home Care Home Base.

Yeah - gone are the days where you could just do your nursing work and get away with a 5 minute paragraph because everybody assumed nurses are doing what they are supposed to be doing ...