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Part 2 seeks to assist both new and experienced hospice nurses and other team members in meeting various requirements and documenting the specific information required by any payer, “painting a picture” of the patient/family’s conditions, concerns, care and responses to care and interventions, and overall, to accurately chronicle the patient’s individualized hospice care.
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HOSPICE DOCUMENTATION: WHY IS THE CLINICAL RECORD SO IMPORTANT?
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The hospice clinical record is a legal document and is the only one that chronicles a patient’s stay from admission and start of hospice care through to death or discharge. It is considered the most reliable source of information about the care provided to the patient and family/caregiver. If the hospice organization has computerized clinical records, the data might be entered at the point of care with the patient and family. It is strongly recommended that the documentation be completed as soon as possible and at the time the care is provided, when possible, to ensure accuracy of the information. The care and practice of hospice team members is described every day to surveyors, payers, peers, and managers in the hospice clinical record. Visit records, notes, and other information that appears in the record reflect the standard of hospice care as well as the unique care provided to a specific patient and family. Documentation that is incomplete or inaccurate places the patient, the nurse, and the hospice organization at risk. Incorrect information in the patient clinical record can endanger patient safety, delay treatment interventions, and negatively impact Medicare payment to hospice providers. Inaccurate documentation leads to increased scrutiny from federal, state, and accreditation surveying bodies as well as Medicare Administrative Contractors (MACs). As regulatory scrutiny increases for hospice, it is imperative for providers to ensure all documentation is accurate, consistent, timely, complete, and paints a picture of the patient and family (Parker, 2020).
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The Centers for Medicare & Medicaid Services (CMS) expects accurate documentation from all providers and will view inconsistent or incomplete documentation as a potential issue that could trigger a survey or an audit. If the hospice provider is compliant with regulatory requirements, but their clinical documentation does not reflect that compliance, it can lead to survey deficiencies. Inaccurate documentation can also lead to incorrect claims to Medicare, which can cost a hospice money in addition to the risk of an audit (Parker, 2020). It is critical for the interdisciplinary team to document at the point of care and add as much detail into their documentation that shows the patient’s and family’s status at the time of care delivery.
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Hospice team members must be able to integrate the knowledge of regulatory criteria, care coordination, and practice into effective documentation that supports coverage while demonstrating quality and value to any reviewer. Third-party payers, such as the MACs, make numerous reimbursement decisions based on the care the patient received as evidenced ...