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Nursing Documentation Requirements Under PDPM: What isn’t new

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Written by Denise Wassenaar, RN, MS, LNHA, VP Clinical & Regulatory Affairs & CCO

Over the past 20 years, patients leaving an acute-care setting were presumed to be covered for skilled services through the need for rehabilitation services. Consequently, the burden of documentation demonstrating the need for skilled services was met by therapists.

Effective with the implementation of PDPM on October 1, 2019, the documentation burden will begin to shift to nursing as patients entering skilled nursing facilities from acute care are admitted with the presumption of coverage for skilled nursing services.

The Medicare Benefit Policy Manual “Coverage of Extended Care (SNF) Services” clearly outlines the requirements for coverage and subsequent documentation when a patient is admitted for skilled nursing services1. None of this is new because of PDPM, but as stated previously, this burden has been historically met by therapy.

When performing Medicare charting keep in mind the following:

  • Nursing documentation must reflect the need for the continuation of skilled care.
  • Nursing staff must document on Medicare A residents at least once every 24 hours and more often if warranted by a resident’s condition.
  • Documentation should include vital signs, why the resident is receiving skilled services and a detailed description of the resident’s condition at that time.
  • Documentation should be specific to the clinical reasons for coverage, services delivered, and response to care.

There are four principle skilled nursing services that require Medicare charting:

    1. Management and Evaluation of a Care Plan
      • The development, management, and evaluation of a patient care plan, based on the physician’s orders and supporting documentation, constitute skilled nursing services.
      • Nurses need to document the services that require the involvement of skilled nursing personnel to meet the patient’s medical needs, promote recovery, and ensure medical safety.
    2. Observation and Assessment of a Patient’s Condition
      • Documentation must reflect when the likelihood of change in a patient’s condition requires skilled nursing to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures until the patient’s condition is essentially stabilized.
    3. Teaching and Training Activities
      • The documentation must thoroughly describe all efforts that have been made to educate the patient/caregiver and their responses to the training.
      • The medical record should also describe the reason for the failure of any educational attempts, if applicable.
      • Topics of teaching include colostomy care, insulin administration, prosthesis management, catheter care, G-tube feedings, IV access sites, and wound care.
    4. Direct Skilled Nursing Services to Patients
      • Nursing services are considered skilled when they are so inherently complex that they only can be safely and effectively performed by or under the supervision of, a registered nurse or when provided by regulation, a licensed practical (vocational) nurse.
      • Some examples of direct skilled nursing services are IV feeding (must meet criteria), IV meds, suctioning, tracheostomy care, rehabilitation nursing procedures, ulcer care, tube feedings, care for surgical wounds, and diabetes management with injections.

In preparation for the anticipated need for increased nursing documentation related to PDPM, the clinical leaders of MatrixCare are reviewing current documentation resources and identifying gaps. This will be a continuous improvement process in which we will seek your guidance to ensure we are developing in the right direction. Look for invitations from Kim Mulquin-Shumway, Senior Clinical Content Specialist, to participate in an upcoming CAB meeting related to clinical documentation.

Find more information on PDPM here.

1 30.3 Direct Skilled Nursing Services to Patients (Rev.179, Issued: 01-14-14, Effective: 01-07-04, Implementation: 01-07-14) A3-3132.2, SNF-214.2

Denise Wassenaar

Denise Wassenaar joined MatrixCare as Chief Clinical Officer in May 2013. A recognized leader in long-term care, Wassenaar brings innovative strategies and solutions to the changing environment of the post-acute provider. She has more than 20 years in the post-acute settings serving as Vice President of Clinical Services for a CCRC organization, President of Alliance Pharmacy Services and other executive positions. Wassenaar holds BS and MS Degrees in Nursing from Purdue University and is a licensed nursing home administrator. She serves on the Board of Directors of a CCRC in Arizona.