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Does Your Documentation System Really Make It Easy To Know What Is Going On With The Patient? Or, Is It Time To Get Back To Basics?

Documentation questions

Over time, home health documentation has changed. Whether we look at the litigious society that we live in or ongoing regulation changes, health care documentation has evolved. The most important thing is to make sure the patient doesn’t get lost in the documentation. Care planning needs to be meaningful to outcome-based patient care. Let’s take an look into the efficacy of your electronic medical record.

The Purpose Of An EMR:

As the goal to eliminate silos between providers in healthcare emerged, so did the need for information to be readily accessible at any time.  Enter the EMR. It allowed standardized assessments and a way for agencies to make sure certain things were documented prior to finalizing a visit for billing. Agencies were able to standardize care plans and interventions. It also allowed easy access whether it was 8:00 in the morning or midnight via a laptop. On call staff had all patient information at all times. It really shows how far we have come in the last 20 years. The question to ask is whether our industry has become better at caring for the patient at home because of it.  If we have 10 times the pages of clinical documentation, then why isn’t the outcome better? You really need to look at the value of the documentation you require from clinicians.

Changes To Clinical Documentation:

If we fall back to documentation prior to the EMR, we saw a flow sheet where clinical data was recorded and pertinent interventions were added. Clinical notes were concise and contained the basic information clinicians needed to know about previous visits. There would be the teaching completed as well as the protime drawn or what dressing was done with a description of the wound. We got down to the nitty-gritty of patient care. With the addition of the EMR, there is so much more clinical data available at any time. This also meant a change to the length of care plans.

It became more normal to see a 485 that is 4 pages long with a beautifully written care plan. However, when broken down through the visits, the clinicians often missed addressing all of the care plan items. It also meant that agencies were unable to meet all the goals on the care plan. In addition, it means care plans did not always make sense with the frequency of how often the patient was seen. How can an agency expect to meet 4 pages of goals if the nurse only sees the patient one time per week?  Often times, care plans became generic and did not have patient centered goals.

Regulation Changes:

First, enter the changes to the Conditions of Participation. Then,  prepare to enter the biggest payment reform with PDGM since PPS in 1999. The role of clinical manager is required with the COP change but it is leading you into what is necessary for PDGM success. We need patient-centered care plans with a focus on goals and objectives leading into 30-day payment periods. The care plan needs driven by the diagnosis and patient goals. It doesn’t make sense to have smoking cessation in care plans when the patient has told the clinician there is no desire to quit smoking. Just because the clinician knows this will help the patient dealing with congestive heart failure doesn’t mean this is realistic for a focused care plan. PDGM’s focus is getting the patient safe and functioning in the home within a shorter period time. This means more intensity to the care we provide.

Let Kenyon Homecare Consulting Take You To The Next Step:

The next step is to streamline your clinical documentation so more focus is on the patient-centered care plan and goals. At Kenyon Homecare Consulting, we focus on providing high quality patient care and helping agencies to thrive while doing it. We can help you achieve the outcomes you desire while educating staff and looking at operational issues. Call us today at 206-721-5091 or contact us online to see how we can help your EMR be everything clinical staff needs while providing quality care in a PDGM based world.

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