MDS Alert

Published on Tue Jan 04, 2011 PDF

These 2 documentation examples can sink claims.

Key: "Nursing and therapy documentation have to speak to" what's going on with the resident and how it relates to the therapy goals, emphasizes Sheila Capitosti, RN-BC, NHA, MHSA, clinical compliance director for Functional Pathways in Knoxville, Tenn. While a daily nursing note should support the skilled services for Part A, you tend to see nursing notes for rehab residents that say things like "went to therapy and tolerated well," she observes.

Instead: Suppose the resident is working on getting from a sitting position to standing so he can move to the wheelchair on his own, Capitosti says. Then "the daily nursing note should talk about what progress the person is making with that goal on the nursing unit. The note might say that the person came back from therapy in the morning and was doing well achieving that goal." But the person regressed to a lower level of function in the evening when he was tired, she adds.

Good question: "What good is an ultra high or very high RUG if the nurse documents 'resident ambulating down the corridor without complaints?'" asked Marilyn Mines, RN, RAC-CT, BC, in a presentation at the fall American Association of Nurse Assessment Coordinators' conference in Baltimore.

"If the resident is receiving therapy for gait training and walking well, with a steady gait, and with no support, etc., it is time to discuss the plan of treatment with therapy," Mines tells MDS Alert. The therapy plan will, of course, change as the resident progresses, she adds. So "maybe therapy is working on strength and or endurance, not gait." And if therapy hasn't written a care plan for nursing to walk the resident, nurses may not be doing that, adds Mines, director of clinical services for FR&R Healthcare Consulting in Deerfield, Ill.

Communication is key: "Therapy needs to communicate with both nursing and activities," stresses Capitosti, "so that all departments are jointly working together to achieve functional goals, and so the documentation from all departments correlates -- and supports the resident's functional outcome goals."