Hospice Charting: Beyond the Checkbox
Every hospice agency does things a bit different. As hospice professionals we know what we know, but we don’t necessarily know what you know or how you do things a bit differently. Before launching Hospice Tools outside of our beta we researched the needs of hospice agencies. We met with a number of hospice pros and discussed what they need and want in an EMR/EHR and why they chose the software that runs their company.
One agency we met with took us through the software they chose – specifically how it runs their IDG. They went with this particular software because their IDG process was totally checkbox driven. If one wanted, all the patients could be batched, and all the clinicians had to do was check a box and IDG was complete. The system treated IDG as a paperwork and process formality and developed the quickest possible shortcut through the required documentation.
After seeing this checkbox driven IDG we reached out to a healthcare legal pro who took one look at it and said, ‘one day they will have an audit, and I wouldn’t want to be in their shoes when that happens.’
Hospice CMS & ZPIC Audits
CMS Guidelines for hospice surveyors states: The IDG works together to develop and update the individualized plan of care for each patient, based on the assessments, to meet the identified patient/family needs and goals. Hospice care documentation must be complete and tailored to each patient. Simple checkbox lists or cut & paste charting will not meet the criteria CMS sets out for regulatory requirements and patient care.
NHPCO has put out a CMS Top Ten Survey Deficiencies Compliance Tip Sheet. 7 Of the top 10 survey deficiencies are related to individualized plans of care. The three plans of care most cited are:
- Plan of Care
- Hospice Aide Plan of Care
- Bereavement Plan of Care
These deficiencies occur on the content, updating of content, and supervision of care delivery matching the plan of care – all of which flow directly into IDG.
Further, as CMS continues to focus on individualized patient care, agencies using checkbox lists and cut & paste charting risk facing a ZPIC (Zone Program Integrity Contractor) audit. ZPIC audits have the ability to suspend payments even without allegations of fraud! ZPIC audits can suspend payments to hospice agencies for alleging lack of medical necessity.
Documentation that is not individualized and comprehensive can create a situation where even if there are no claims of fraud, payments to your agency may be suspended.
Hospice Documentation for CMS & Patient Care
CMS states its core requirement for documentation in MBPM 5-11-2015. “Clinical notes should be written such that they adequately describe the reaction of a patient to his/her skilled care. Clinical notes should also provide a clear picture of the treatment, as well as ‘next steps’ to be taken.”
Based on this guideline, it’s clear that CMS expects patient care to be documented in a manner that presents a complete picture of what problems are being addressed, and how the hospice agency plans on dealing with the problems.
Checkbox lists and cut & paste charting cannot provide a clear and comprehensive picture of the patient’s issues nor, demonstrate a medical necessity for the care provided or how the next steps fit into an individualized care strategy. Clear and robust documentation will not only protect your agency in an audit, it will also provide the information care-providers need to consistently deliver quality individualized care.
Understandably, hospice agencies want their clinicians time and energy focused on patient care and documentation is often thought of as a regulatory issue, an afterthought rather than its own pro-active form of patient care. However, despite the time crunch and other stresses that clinicians and hospice agencies face on a daily basis, clear and complete documentation will ultimately save time and money and deliver an overall more positive patient and caregiver experience.
The problem is not with checkboxes. Dropping checkboxes and replacing them with cut & paste text that views patients with the same conditions as receiving the same treatment, or short text that has no meaning i.e.: ‘follow the PoC’, is no solution either.
The solution is a blend of checkboxes for categories and text fields for individualized care.
Check out how Hospice Tools handles care plans – a blend of check boxes with editable text and free text fields. This blend helps guide clinicians through the documentation process, while intuitively demanding that the documentation be personalized to each patient.
One of the great benefits of the Hospice Tools EMR is the flexible forms library which gives us the ability to edit or change forms. When the team’s workflow isn’t capturing all the data you need and you need or you want to change your documentation workflow, the Hospice Tools flexible forms library allows us to easily make changes to existing forms or swap out whole forms. Unlike other EMR systems with hard-coded fields and workflows, Hospice Tools forms are not embedded into the system; they stand alone in an integrated library. This allows us to create a new form or remove an old one without needing to change the code of your software itself. This flexibility allows us to react quickly to changing needs an updated guidance or regulations
Hospice Tools Simplifies Hospice Management
Hospice Tools is the software solution built for hospice. Our intuitive EMR / EHR delivers user-friendly point-of-care charting with automatic workforce management tools and simplified billing. Hospice Tools is cloud-based with web-login for desktop/laptop and true Android and iOS mobile apps with full functionality.
Our fully integrated suite of tools: eDocs EMR, TimeKeeper integrated timesheets, and eBilling for hospice & palliative financial management, empower your agency to work smarter, get paid faster, and stay automatically in compliance.
To learn more about how Hospice Tools can help your hospice & palliative agency with user-friendly and compliant documentation, alongside breakthrough features such as Mentor Mode, Volunteer Mode, Audit Mode and more, check out our No risk free-trial or Contact Us today!