Improving Clinical Documentation: Effectively Coaching ... · 1) Clinical a) Patient Safety b)...
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Management Session – May 18, 2012 www.ahpco.org Page 1 2012 Spring Conference MANAGEMENT SESSION Improving Clinical Documentation: Effectively Coaching Nurses to Adapt Habits that Meet Standards Presenters: Sharon Corbett, RN, Surveyor, Arizona Department of Health Services Jacey LeClair, RN, BSN, CHPN, Director of Clinical Services, Evercare Hospice Nancy Zonnevylle-Jackson, RN, MSN, CHPN, Triage Nurse, Hospice Inspiris Session Objectives: 1. Describe common challenges among hospice nurse case managers related to documentation 2. Explain the consequences of incomplete nursing documentation 3. Identify resources for improving documentation 4. Review Strategies for coaching nurses. Challenges Describe Challenges You Experience within Your Organization: • • • • Consequences 1) Clinical a) Patient Safety b) Quality of Care c) Other: 2) Quality Improvement a) Benchmark b) Continuity of care delivered c) Other: 3) Financial Penalties a) Reimbursement b) Citation/Review c) Discharge d) Other: 4) Legal a) Litigation b) Fraud c) License Revoked d) Other:
Transcript of Improving Clinical Documentation: Effectively Coaching ... · 1) Clinical a) Patient Safety b)...
Management Session – May 18, 2012 www.ahpco.org Page 1
2012 Spring Conference MANAGEMENT SESSION Improving Clinical Documentation: Effectively Coaching Nurses to Adapt Habits that Meet Standards Presenters: Sharon Corbett, RN, Surveyor, Arizona Department of Health Services Jacey LeClair, RN, BSN, CHPN, Director of Clinical Services, Evercare Hospice Nancy Zonnevylle-Jackson, RN, MSN, CHPN, Triage Nurse, Hospice Inspiris Session Objectives:
1. Describe common challenges among hospice nurse case managers related to documentation
2. Explain the consequences of incomplete nursing documentation 3. Identify resources for improving documentation 4. Review Strategies for coaching nurses.
Challenges Describe Challenges You Experience within Your Organization:
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•
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Consequences 1) Clinical
a) Patient Safety b) Quality of Care c) Other:
2) Quality Improvement a) Benchmark b) Continuity of care delivered c) Other:
3) Financial Penalties a) Reimbursement b) Citation/Review c) Discharge d) Other:
4) Legal a) Litigation b) Fraud c) License Revoked d) Other:
Management Session – May 18, 2012 www.ahpco.org Page 2
Who Can Review our Records*? There are more than 10 different types of agencies/contractors that can review your records. Government Agencies: Medicare Contractors: • DOJ – U.S. Attorney’s Office Civil & Criminal • Office of the Inspector General (OIG) • Federal Bureau of Investigation (FBI) • Arizona Department of Health Services (DHS) • State Attorney General’s Office • State Medicaid Fraud Control Units • State Office - Medicaid Inspector General
(OMIG) • Medicaid RACs • Medicaid Integrity Contractors
• Quality Improvement Organizations • Program Integrity Units & Fiscal Audit • Medicare Administrative Contractor • Recovery Audit Contractors (RAC) • Zone Program Integrity Contractors (ZPIC)/
Program Safeguard Contractors (PSC) • Medicare Secondary Payer Recovery
Contractors • Comprehensive Error Rate Testing Program
(CERT)
What are the Hot Issues*?
• Narratives. • Face-to-Face (completed and timely) • Lack of justification in the record for hospice eligibility. • Hospice services provided in the nursing home. • Lack of justification in the record for level of care provided.
*Excerpted from Regulatory Issues Presentation, Judi Lund-Person, MPH, NHPCO COS Meeting, March 2012 Resources & Strategies Resource/Strategy Pros Cons
Next Step Describe one action or change you will implement as a result of today’s session:
