This post may contain affiliate links. I will make a small commission if you make a purchase through one of these links, at no extra cost to you. Please read full disclosure for more information.
Hospice documentation is tedious and time-consuming. However, it doesn’t have to be that way.
I’ve outlined simple tips to help you master the fundamentals of hospice documentation.
Do you spend hours documenting at home? Worse yet, do you find yourself frustrated when “corporate” only seems to care about timely documentation?
I get it. Truth be told, I used to be “corporate.”
(Don’t judge me!)
Regardless of how you feel about it, one fact remains. Documentation is king!!
Why Hospice Documentation Matters
First, like all nurses, hospice nurses are required to document ALL patient care.
Inaccurate and inconsistent documentation is a red flag and could have a negative impact on your patients, your license, and your agency.
For instance, audits, deficiencies, and legal actions are just a few of the consequences of poor documentation.
Another important consideration is hospice documentation supports the patient’s eligibility for admission and recertification to hospice.
Therefore, your documentation should tell the patient’s story.
Now, back to why corporate is on your back. When you don’t document, Medicare doesn’t pay. This can have a trickle-down effect.
Think of it this way, if Medicare repeatedly denies payment, then you might not get that raise you deserve.
I’m just being honest because this is the stuff your supervisor may not always explain.
Common Barriers to Hospice Documentation
- Attitude about documenting in front of the patient
- Short staffing
- Unclear understanding of hospice rules/regulations
- Lack of nursing experience (new to hospice)
- Inappropriate assignments (new nurse with complex patients)
- Travel time (rural vs nursing home vs inpatient)
- Too many patients
Related Article: 3 Common Mistakes Hospice Nurses Make and How to Avoid Them
Hospice Charting Fundamentals
Let’s begin with the basics. Your documentation is the foundation for the care your patient needs from you and the interdisciplinary team.
It also outlines the plan of care, serves as a communication tool, and supports your nursing actions.
As a hospice nurse, you should:
Document at the bedside: First to ensure accuracy then to make sure the team has the information they need to care for the patient.
(I’ll be honest, nothing gets under my skin more than not knowing what medications my patient is actually taking!)😠
Be specific: It should be clear to anyone who reads your notes, what the patient’s problems and needs are.
Individualize the plan of care: Each patient has unique needs and your plan of care should reflect them.
Avoid the temptation to copy and paste your previous notes and/or plan of care.
Be concise: Don’t add fluff to your notes. Also, try to stick to the most pertinent problems that need to be addressed.
Use a checklist: A hospice documentation template or cheat sheet can be used to ensure you don’t miss anything during your visit.
Chart all calls: Phone calls and triage notes inform the team. They also demonstrate how the team is educating and supporting the patient’s families and caregivers. You should also document all calls to the physician as well. (If a patient calls more than twice about the same issue i.e., pain, SOB, foley issues, they need a visit!)
Document using hospice scales: Medicare uses scales to determine eligibility. They also paint the picture about the patient’s activity, mental status, and decline.
CommonHospice Scales & Measures
These scales are just one way to document hospice eligibility and changes. The most common hospice scales are:
- PPS– Palliative Performance Scale
- KPS-Karnofsky Performance Status
- NYHA– New York Heart Association Functional Classification
- FAST-Functional Assessment Staging Test
- MUAC-Mid Upper Arm Circumference
EXPERT-TIP: Focus on what the patient needs. For instance, don’t add a fall problem to the plan of care if the patient isn’t a fall risk.
Don’t add compromised nutrition if they don’t have a nutrition problem. Just because you anticipate a problem, doesn’t mean it needs to be an active problem.
My point: Individualize as much as possible.
Negative Charting and Ongoing Eligibility
When you are new to hospice, you might be tempted to chart positively about your patient’s condition.
After all, nurses are trained to help their patients get better. You might be used to documenting statements such as “patient doing well”, or “patient had a good day.”
As a rule, you should avoid subjective, biased documentation. Below are examples of documentation that supports ongoing hospice eligibility. This is often referred to as negative charting.
- Change in pain (frequency/intensity)
- Increases and/or changes needed to pain medication
- Worsening symptoms (i.e. breathing, edema)
- Increased dependance in ADLS
- Weight changes
- Appetite changes
- Mental status changes
- Incontinence (new or increased)
- Worsening labs i.e., decreased albumin
- New compromised skin integrity (wounds)
- Decreased MUAC
- Increased abdominal girth
- Change in oxygen demand
- Changes in level of care i.e., respite, general inpatient, or continuous care
Common Hospice Documentation Problems
Inconsistent documentation
For instance, the nurse documents that the patient is totally bed-bound (PPS 30%) but the hospice aide states the patient uses a walker.
Additional red flags could include dramatic differences in weights or mid-upper arm circumference (MUAC) measurements.
Another issue that can occur is with the hospice aide care plan. For example, you enter an order and care plan for showers, but the aide documents a bed bath was given. This could result in a deficiency.
In this case, the hospice aide should notify you of the change in the patient’s condition. Then you should obtain an order to change the plan of care to bed bath and finally, update the plan of care.
When this type of information is documented, it supports the concept of coordination and communication regarding the patient plan of care.
According to an OIG report, 80% of hospice agencies had at least one deficiency.
Incomplete documentation
An example could be not using hospice scales to explain how the patient meets hospice eligibility criteria.
Poor word choices
Let me start by saying, do NOT embellish your notes to meet criteria!
However, there are a few words that don’t tell the story when used in hospice. For example, don’t use stable, doing well, and unchanged. These words may imply that the patient should not be in hospice.
Not documenting changes
Honestly, changes happen quickly in hospice. And to make matters worse, you might not always be present when they occur.
Remember to document falls (even if you are not immediately notified), changes in mental and physical status, and other signs of decline.
Not following the plan of care
One of the most common deficiencies hospice agencies receive is for not adhering to standard§418.56(b)(c) Standard: plan of care. This is a common deficiency that occurs in hospice during surveys.
Additionally, the interdisciplinary team (IDT) should meet no less than every 15 days to update the plan of care. Each member should contribute to the plan of care.
Expert Tip: Don’t make the initial plan of care longer than it needs to be! If you’re using electronic software, it can be tempting to select automatic pop-ups. DON’T!!
Do’s & Don’ts of Hospice Documentation
Conclusion
In summary, there are many factors that can impact your documentation.
Not only is hospice documentation time-consuming, but it also takes you away from direct patient care.
So, let’s be real when you’re busy, you might be tempted to cut corners.
However, your documentation is the key to providing the best care for your patients. It’s also your best defense in a court of law.
Finally, you should apply the fundamentals to ensure that you’re documenting the most pertinent information as accurately as possible.
Remember, the more individualized your charting, the better care your patients and families receive.
Suggested Article: Hospice IDG: Top Time Wasters and How to Avoid Them