primary diagnosis and co-morbidity

[Hospice Nurse LPN, BSN, RN]

I was taught that documentation should be toward the primary diagnois and not the co-morbidities. All charting should be negative. For example, if the pt has Alzheimer's then I should not be documenting about the glucose level and the heart murmer.

I changed jobs a couple of weeks ago and the nurse working with me in orientation listed all the co-morbidities (and discussed in the narrative) for each patient on the nurse note. I asked her why and she just said "because we are supposed to". I thought that sounded like a home health answer -- not hospice.

I'd appreciate any input. Thanks!

Sharon :caduceus:

[leslie :-D]

hi sharon,

don't you use a form that allows you to address all of the body systems?

i usually address all symptoms that interfere with a pt's distress levels.

the doctors billing for services are coded with the various dxs they are dealing with.

i'm not sure if everyone does it the same...

leslie

[kokobean]

I was taught that documentation should be toward the primary diagnois and not the co-morbidities. All charting should be negative. For example, if the pt has Alzheimer's then I should not be documenting about the glucose level and the heart murmer.

I changed jobs a couple of weeks ago and the nurse working with me in orientation listed all the co-morbidities (and discussed in the narrative) for each patient on the nurse note. I asked her why and she just said "because we are supposed to". I thought that sounded like a home health answer -- not hospice.

I'd appreciate any input. Thanks!

Sharon :caduceus:

Sharon

I have been a hospice nurse for 15 years and am now a hospice educator. When I make a visit, I make sure to document all perteinet findings. I also documernt any decline in the pateint. Documentation needs to show some sort of decline if applicable, this will help when you need to recertify the patient. I document mainly on the primary diagnosis but if the co-morbitites are influecning deline than I document on that also. An example of documentation would be the patients vital signs, document delcine for example the patient is depdendent in 3 out of 6 adl's then if the pateint delcines and now needs assistance with say 5 out of 6 adl's it will be easiler to recongize the decline. I hope this helps

[Hospice Nurse LPN, BSN, RN]

Thank you for your replies. I'm guessing my question wasn't really too clear. Kokobean's answer sounds alot like the way I chart. Of course, I'm checking vitals and listening to lungs, abd no matter the diagnosis. The way it was explained to me was that if I was charting on everything, then hospice would be responsible. For instance, the Lung CA pt who is still getting dialysis....I wouldn't document on the renal function or dialysis.

[aimeee, BSN, RN]

The way it was explained to me was that if I was charting on everything, then hospice would be responsible. For instance, the Lung CA pt who is still getting dialysis....I wouldn't document on the renal function or dialysis.

When a patient is under hospice care then Hospice is the care manager

which means we retain ultimate responsibility for the coordination of the total care plan. Therefore, nothing is truly outside our realm. You continue to be responsible for making sure that the patient's needs are met and symptoms are controlled regardless of whoever else is involved. Charting by exception is the most expedient but the only way to show that everything is being addressed is to at least mention each area and state that no changes are observed, or current care plan effective, or some such thing. We are whole beings and all the co-morbidities affect the function of the other systems as well.

[doodlemom]

When a patient is under hospice care then Hospice is the care manager

which means we retain ultimate responsibility for the coordination of the total care plan. Therefore, nothing is truly outside our realm. You continue to be responsible for making sure that the patient's needs are met and symptoms are controlled regardless of whoever else is involved. Charting by exception is the most expedient but the only way to show that everything is being addressed is to at least mention each area and state that no changes are observed, or current care plan effective, or some such thing. We are whole beings and all the co-morbidities affect the function of the other systems as well.

I totally agree with Aimeee. Yes, you are supposed to be documenting on decline in status but documenting on other problems does not mean that your hospice is responsible for paying for them. For instance - you could report that your patient that has lung CA had dialysis treatment yesterday and tolerated poorly/well. We are supposed to be taking care of the whole person - not just their diagnosis. Another example is a patient that I had with lung cancer who also had a long hx of HTN and heart disease. Her HTN got out of control while she was on service and I called her cardiac doctor and received orders to increase her BP meds. The last thing she needed was to have a stroke!

[a21chdchic]

6-26-2007

The Hospice RN Case Mgr. is responsible for the whole patient and seeing to all areas of the patient. I, as a Case Manager, assess the whole patient and would expect anyone who seen any of my patients to report and document all pertinent findings outside the norm to me, so that I can ensure the proper treatment to manage my patient's symptoms and keep him/her comfortable, regardless of the Diagnosis we have admitted him/her for. If it is a symptom that should be managed by another MD, it is my job to ensure that the symptom is appropriately treated.

Ana