Medicare Nursing and Skilled Nursing Facility Documentation

Sharpen Your Skilled Nursing Facility Therapy Documentation Know-how

Plus, know if Centers for Medicare and Medicaid have specific documentation guidelines to meet requirements for Part A skilled services

Read the following expert advice and avoid your skilled nursing facility therapy documentation woes.

Can daily nursing and therapy notes not equally reflect the same level of function for a patient?

The answer would be Yes. That is true because nursing is assessing a patient over a 24-hour period of time. And therapists are assessing a patient over a much shorter period, much shorter window for that day.

So therapists – oftentimes people say, “Oh, you know, therapists say that the person is requiring, you know, contact guard assist or a limited assist if you're using MDF language.” But nursing staff is saying that patient requires extensive assist. And how can that be?

And the way that can be is because the therapists have a very manipulated environment. They have therapeutic environment that is going to facilitate the patients’ highest level of function. And after therapies are done with the patients and they're exhausted. And they go back to the unit that patient is going to be fatigued and, you know, they may have some muscle pains following their hard work with therapy.

And so, it certainly could be that the notes would not match. And what needs to happen is the MDS coordinator or somebody coordinating the record should clearly state, you know, where the patient is functioning most consistently. And make sure that it's clearly delineated, you know, that the patient functions at this level therapies but following therapy intervention, the patient is significantly fatigued and requires additional assist for transfer in and out a bed or whatever.

But certainly that is appropriate to have therapy and nursing have different types of level of function documented.

Baseline Evaluation Information

Should therapy treatment be substantiated with specific and measurable baseline evaluation information?

The answer would be, absolutely. There always needs to be an evaluation and CMS just clarifies that in the final rule that came out in August in 8 '08. They talked about that there needs to be a therapy evaluation on file or completed anytime a patient is admitted under Medicare Part A. So if that patient goes out for several days and then comes back and is readmitted, therapist needs to do a new evaluation. It needs to be documentation.

Long Term Care Training Tip: And the evaluation should be very as measurable as possible for that evaluation because that is going to support any gains that has been made by the patient. And oftentimes, therapist tends to get away from doing the goniometry measurements and really having some clear manual muscle testing measurement.

But that is what Medicare is looking for. They're looking for some comparisons. And when you do your eval to be as detailed as possible, you know, it's a challenging population certainly. We're not dealing with an outpatient population. We're dealing with the SNF population.

And so, you're doing things that are definitely not as standard as in some other setting. But as measurable as you can make your data on your evaluation, the better. That doesn’t really show a specific measurement. And it needs to be quantified or clarified for that particular patient because what if that patient does start to show and issue down the road as you're seeing that patient in an area that was otherwise documented as within functional or normal limit. You didn’t really have a true measure to begin with.

Part A Skilled Sevices

Does the Centers for Medicare and Medicaid have specific documentation guidelines to meet requirements for Part A skilled services?

Basically, CMS or Centers for Medicare and Medicaid, they're requirement is that documentation supports the provision of daily skilled services. So they do not have a specific guidelines that says you must document vitals every day, you must document O2 (stuff) everyday.

What they say is that you need to prove that daily skilled care was delivered. So that's why we have, you know, these presentations makes discussions so that people understand what skilled care is and how do I document, that I provided skilled care every day.

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