Hospice documentation makes up the clinical record of a patient receiving hospice services. CMS is looking for documentation that is complete, thorough, and patient-specific. As a result, hospices that have long relied on cloning and “checkbox charting” methods are facing the reality of adopting new documentation methods that satisfy regulatory requirements and enhance patient care quality.
As regulatory requirements change, and as CMS continues to shift its sights to more patient-centered, comprehensive documentation, agencies using checkbox charting methodologies could be more likely to end up facing a ZPIC investigation, according to a Home Care Technology Report article. Because of this, agencies should begin adapting their hospice documentation accordingly.
Implementing comprehensive and thorough hospice documentation methods makes it easier to document and track care activities that are fine-tuned to individual patients and loved ones, resulting in a personalized care experience, better quality, and greater transparency across care teams. However, the additional time and attention that goes into this kind of hospice documentation can be intimidating for agencies already facing regulatory pressures and time constraints.
New Hospice Documentation Approach
How can you successfully thrive under this change in hospice documentation methodology? At their core, hospice care notes should build upon one another, demonstrate the medical justification for the care provided, and establish how procedures fit within care strategies. They should tell the complete patient care story while still being achievable, complete, and concise.
When thinking about your hospice documentation… Does it tell the story of the patient’s eligibility for hospice? Does it have enough detail without being overly robust? Does it look like it belongs to the patient you are caring for? Does it look like the same documentation as your other patients?
Demonstrate Patient-Centric Care
The Hospice CoP §418.56(c) Standard: Content of the plan of care; L545 states that, “the hospice must develop an individualized written plan of care of each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments.” Between 2014 and 2016, failing to comply with this CoP was one of the top four hospice survey deficiencies. You must ensure that your care plans are specific to your patients or you could be out of compliance.
Problems should be addressed by documenting goals and interventions that make clinical sense. Only identify goals and interventions that pertain to the clinical problems you are trying to resolve for a particular patient. Create clinically appropriate care plans that are realistic and achievable.
It is very easy to fall into a trap of quickly checking boxes and cloning narratives about a patient with a particular problem because, “a patient with that problem always receives the same treatment.” However, that is exactly what CMS does NOT want you to do. They are expecting that you have used your clinical judgment combined with the evidence before you to create a care plan tailored for that patient, and that patient alone.
Details are Important…But Be Concise!
Keep in mind that your hospice documentation is the basis for what care your patients need and will receive, what information and assistance loved ones are given, and how your agency will be paid. With detailed documentation, you will equip the entire care team with the information needed to better assist your patients and their loved ones. Stronger, detailed documentation will also stand up to the greatest levels of regulatory, legal, and public scrutiny.
While the details are crucial, do not get stuck down a rabbit hole of over documenting. Provide information in a succinct manner with clear explanations with just the right amount of detail. Do not include so much that others have to sift through mountains of notes to see what they need to see.
Record only facts, and not opinions about the facts. Accurate hospice documentation is true documentation.
Consistency is Key
Hospice documentation is consistent when it supports the plan of care, the orders, observations that you or other members of the care team have made. All details should match each other and problems, goals, and interventions should correspond accordingly.
Each member of the care team should not only share information, but should compare with other members to ensure that you are not only documenting consistently across the care team, but that you are documenting consistently for each individual patient.
How Hospice Software Helps
One of the most important functions of hospice software is streamlining the hospice documentation process. Through optimized EHR use, hospices can enhance the quality of patient care and improve efficiency.
Hospice software enables accurate, up-to-date, and complete patient information at the point of care and beyond, allowing for more coordinated, efficient care. All software should include clinical workflows that follow standard care processes and that direct your focus on patients and caregivers, not solely on hospice documentation. It should also equip clinicians with comprehensive, evidence-based guidance designed to reinforce sound decisions at the point of care.
HEALTHCAREfirst Has You Covered
Fully integrated with our hospice software firstHOSPICE, CAREpliance™ clinical decision support technology shortens hospice documentation time and allows you to manage compliance with ease. You can easily build a plan of care, utilizing comprehensive decision support functionality that suggests problems, goals, and interventions specific to the patient.
To learn more about how firstHOSPICE with CAREpliance technology can help your hospice achieve complete, compliant documentation, contact us today!