Documentation Tips
(Taken from Palmetto GBA)
- Paint a picture of the beneficiary’s condition. Documentation should not merely summarize the beneficiary’s condition for the month, but also show daily and weekly notes.
- Documentation should illustrate why the beneficiary’s medical condition is considered terminal and not chronic.
- Each beneficiary’s documentation should be specific to that individual beneficiary. While checking a form is helpful to indicate what you are assessing, please write in any additional information that will distinguish this beneficiary from others with the same disease, that are chronic and not terminal.
- Upon admission and recertification, assess the beneficiary’s condition and hospice appropriateness. Be sure the documentation distinguishes between exacerbation and stabilization and exacerbation and deterioration.
- Explain your provider’s terminology and documentation methods, especially those that are specific to your agency.
- Document all pertinent diagnosis codes, which relate to the beneficiary’s terminal condition and hospice appropriateness.
- Is the beneficiary receiving any medications, treatments or services, which could be considered aggressive? Please document why these treatments are considered necessary for palliative treatment.
- If a beneficiary is determined no longer to be terminal, then the beneficiary should be discharged from the hospice benefit.
- Nursing documentation should describe the beneficiary’s medical condition. It should reveal to a medical review team that the hospice is continually assessing the beneficiary’s prognosis by specifically documenting the individual patient’s medical symptoms and impairments.
- Social Worker, pastoral counselor, volunteer and any other member of the interdisciplinary team should document their interaction with the beneficiary, family and caregivers, and how they are carrying out their part of the plan of care. All submitted documentation is important and will be reviewed by the medical review team. Non-nursing documentation may help give the medical review team additional insight into the beneficiary’s condition.