LTC Health Information Practice & Documentation Guidelines
Version 1.0
September 2001

6.0 DOCUMENTATION IN THE LONG TERM CARE RECORD

Documentation in long term care has become increasingly complex as the resident’s clinical needs have become more complex, regulations and surveys more stringent, documentation –based payment systems implemented, and litigation/legal challenges have increased.

This section creates a foundation for documentation by addressing the minimum content as required by federal regulation for long term care facilities and fundamental practice standards, but generally does not outline specific content. The tag number for the Federal Condition of Participation is referenced where applicable. This section also addresses common documentation issues and concerns and establishes guidelines or provides recommendations on how to handle common problem areas.

As long term care facilities establish or review their documentation system, the practice guidelines and federal regulations identified below must be taken into consideration. In addition to the federal regulations and professional practice standards, it is imperative to review and incorporate state regulations, accreditation requirements (i.e.JCAHO), and payer requirements into the documentation systems established.

Because documentation systems should be created to meet the needs and unique practices of a long term care facility or organization, this section does not recommend a specific system. Instead, minimum requirements are established, issues to consider are discussed, and guidelines are provided to assist facilities with implementing or evaluating a documentation system while retaining flexibility in how it can be created.

6.0.1 Federal Regulations Pertaining to Clinical Records:

Federal regulation (F514) requires that a the facility "must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized."

The guidelines in this document provides the foundation for "professional standards and practices" as established by AHIMA for clinical records/health information systems. Other professional organizations may have additional standards in dealing with documentation unique to a specific discipline.

6.0.2 Purpose of the Documentation

On a fundamental level, a complete record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual, has adequate plans of care and provides sufficient documentation of the effects of the care provided. Documentation should provide a picture of the resident and their response to treatment, changes in condition and changes in treatment.

6.0.3 Elimination of Duplication/Redundant Information when Evaluating/Implementing a Documentation System:

One of the most significant problems found in many documentation systems is the duplication or redundant information that is collected in the medical record. Not only is this inefficient, but it creates conflicts and contradiction in the documentation that leads to confusion and diminishes the credibility of the record. A common problem found in long term care records is the duplication of information that is collected on different assessments and between the disciplines. To address this issue, long term care facilities should evaluate their entire documentation system looking at the data elements collected by all disciplines and eliminating areas of duplication.

One method to use in evaluating duplication is to create a data dictionary or a list of documentation elements collected in the entire documentation system, identify where it is collected (i.e. what form), how often, and by whom. Once it is known where information is collected and areas of overlap are identified, decisions can be made on elimination of duplicative information. When working with different disciplines, the goal should be creating a system that works together as an interdisciplinary team rather than segregating assessments and documentation into department-specific documents that don’t work together but increase the likelihood of contradictions.

6.1 DOCUMENTATION CONTENT IN A LONG TERM CARE RECORD:

6.1.1 Admission Record:

Every clinical record should have a face sheet or admission record that provides demographic information, responsible party and contacts (F157), financial and insurance information, and contact information for outside professionals involved in the resident’s care (i.e. attending physician, alternate physician, etc.). The face sheet should be kept up to date as changes occur.

6.2 Assessments:

Assessments are critical to the documentation system in a long term care record. It is important to recognize that assessments can be documented in a variety of ways but typically fall into two groups – completion of an assessment form or documenting an assessment narratively. Many "assessments" collect information or identify a condition. To be complete, they should also include conclusions, recommendations and interventions. To be an assessment rather than just a data collection tool, the following elements should be in place:

1. Evaluation -- data is collected relevant to the issue being assessed.
2. Conclusion -- the assessor interprets and documents their conclusions based on the data collected
3. Plan -- based on the type of assessment, there should be a plan with recommendations and follow-up.

6.2.1 Integrating Assessments with RAI Process:

As LTC facilities evaluate their documentation system, the goal should be to create an interdisciplinary assessment process that uses the RAI as the foundation rather than a supplement. With the MDS and RAPS as the main assessment tools, other assessments would collect information that supplements the comprehensive assessment rather than readdress it.

6.2.2 Types of Assessments and Requirements:

The following assessments represent those required by federal regulation or those that have become a standard of practice in the industry. Although many of the assessments are completed on a separate form, the format may vary or the assessment may be documented in narrative notes.

6.2.2.1 Preadmission Assessment:

Completion of a preadmission assessment is not required by federal regulation, but is commonly completed to determine the needs of the resident and assure that the facility has adequate resources and expertise to provide care. As Medicare reimbursement moved to a prospective payment system partially based on services delivered prior to admission, the preadmission assessment has taken on a new purpose in providing supporting documentation for the MDS. If the information from the preadmission assessment is used to support other documents in the record including the MDS, it should be incorporated into the legal medical record and meet legal documentation requirements (completed in ink, authenticated, and dated).

6.2.2.2 Admission Assessment:

An admission or readmission assessment typically incorporates items that would be considered a nursing assessment or physical examination. Although there is not a federal regulation to perform an admission assessment, professional practice standards for the industry indicate that an admission assessment should be completed. State regulations may provide specific detail on information to collect such as vital signs, a review of systems, pain, etc. The purpose of the admission assessment is to collect baseline information on the resident and assist with initiating an initial admission care plan until the MDS, RAPS and care plan process is completed.

6.2.2.3 Fall Assessment:

(F324) Based on the comprehensive assessment, the RAI incorporates a fall risk assessment into the MDS and RAPS. The facility must identify each resident at risk for accidents and/or falls and adequately care plan and implement procedures to prevent accidents. On admission, due to the time delay in completing the RAI, it is recommended that the risk for falls be assessed on admission/readmission (i.e. could be incorporated into admission assessment) and appropriate action taken. The RAI can be used to assess fall risk at times thereafter (quarterly, annually, and significant change in condition). Another type of assessment should be completed after a fall. A post-fall assessment should assess the circumstances of a fall, draw conclusions about the cause of a fall, and implement a plan if appropriate. This type of assessment may be completed in the narrative notes or on a separate form.

6.2.2.4 Skin Assessment:

(F314) Based on the comprehensive assessment the facility must ensure that a resident who enters the facility without a pressure sore does not develop pressure sores unless the individual’s clinical condition demonstrates they are unavoidable. An assessment of current skin status upon admission/readmission is recommended to serve as a baseline. A resident having pressure sores must receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

6.2.2.5 Bowel and Bladder Assessment:

(F316) Based on the comprehensive assessment the facility must ensure that a resident who enters without a catheter is not catheterized without medical justification, a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.

6.2.2.6 Physical Restraint Assessment:

(F221) Prior to a physical restraint being used an assessment must be completed to determine whether a restraint is necessary and if so, the least restrictive device to treat the resident’s medical symptom(s). Prior to a restraint being applied, the facility must assess the resident's bed mobility, ability to transfer between positions, ability to transfer to and from bed or chair, and ability to stand and transfer to the toilet and so forth. Once a restraint is applied, the facility must reassess its use on a periodic basis. The facility should use the Physical Restraint RAP to evaluate the appropriateness of restraint use. (Transmittal 20 - revisions to Appendix PP of the State Operation Manual effective 9/2000)

6.2.2.7 Self-Administration of Medication:

(F176) The interdisciplinary team must determine that it is safe for the resident to self administer drugs before the resident may exercise that right. Appropriate notation of these determinations should be placed in the resident’s care plan. If the resident chooses to self-administer drugs this decision should be made by the time the care plan is completed within seven days of the completion of the comprehensive assessment and then on an on-going basis.

6.2.2.8 Nutrition Assessment:

(F325) The resident must maintain acceptable parameters of nutritional status taking into account the residents clinical condition or other appropriate intervention when there is a nutritional problem. The nutrition assessment should address these issues and include identification of the factors that put the resident at risk for malnutrition. Evidence of review of the RAP for Nutritional status should be present to assess the causal factors for decline, potential for decline or lack of improvement for residents at risk. The individual goals of the plan of care must be periodically evaluated and if not met alternative approaches should be considered or attempted.

6.2.2.9 Activities/Recreation/Leisure Interest Assessment

(F248) The resident's activity program should occur within the context of each resident’s comprehensive assessment and care plan. Clinical records and activity attendance records should reflect individual resident history, interests and preferences indicated by the comprehensive assessment and consistent with the intent of the RAI/care plan process. Outcomes/responses to activities interventions are identified in the reassessment of the resident.

6.2.2.10 Social Service:

(F250) It is the responsibility of the facility to identify the medically related social service needs of the resident and assure that the needs are met by the appropriate discipline. Clinical records should reflect how facility staff implement social service interventions; evidence of monitoring the resident’s progress in improving physical, mental and psychosocial functioning; goal attainment been evaluated and the care plan changed accordingly. Evidence should support that social services interventions successfully address residents’ needs and link social supports, physical care and physical environment with residents’ needs and individuality.

6.2.2.11 Mental and Psychosocial Functioning:

(F319) Based on the comprehensive assessment the facility must ensure that a resident who displays mental or psychosocial adjustment difficulty, receives appropriate treatment and services to correct the assessed problem. (F320) For a resident whose assessment does not reveal a mental or psychosocial adjustment difficulty, there is not a pattern of decreased social interaction and/or increased withdrawn, angry or depressive behaviors, unless the resident’s clinical condition demonstrates that such a pattern is unavoidable.

6.2.2.12 Restorative/Rehab Nursing Assessment:

(F317) Based on the comprehensive assessment the facility ensures that a resident who enters without limited range of motion does not experience a reduction in range of motion unless the residents clinical condition indicates that it is unavoidable. (F318) A resident with limited range of motion, receives appropriate treatment and services to increase range of motion and/or to prevent further decline.

6.3 Resident Assessment Instrument (RAI) - MDS and RAPS

(F274) Each facility must complete a comprehensive assessment which is based on a uniform data set. Facilities must use their State specified RAI (which includes both the MDS, utilization guidelines and the RAPS) to assess newly admitted residents within 14 days, conduct annual reassessment, and assess those residents who experience a significant change in status or when completing a significant correction of a prior full assessment. . No less than once every quarter (92 days), facilities must review the comprehensive assessment to assure that the resident’s assessment is accurate and reflects the resident’s current status.

A comprehensive assessment must be completed within 14 days after the facility has determined that there has been a significant change in the resident’s physical or mental condition (F274). A significant change is defined as a major decline or improvement in the residents status that will not normally resolve itself without further intervention by staff or by implementing standard disease related clinical interventions, that has an impact on more than one area of the resident’s health status and requires interdisciplinary review of the plan of care or both.

The facility is responsible for addressing all needs and strengths of residents regardless of whether the issue is included in the MDS or RAPS. The facility is also responsible for addressing the resident’s needs from the moment of admission.

The MDS is also used to determine the reimbursement level under the prospective payment system for Medicare Part A residents in a SNF. Based on the MDS scoring, a Resource Utilization Group (RUG) is assigned which determines the per diem payment. While on Medicare Part A, the PPS MDS schedule includes a 5, 14, 30, 60, and 90 day assessment. An OMRA (Other Medicare Required Assessment) may also be completed in specific situations. In addition to Medicare, some states may also use the MDS to determine the payment level for medical assistance.

6.4 Care Plan:

The care plan is the foundation that provides direction to the interdisciplinary team and staff on providing care and treatment to the resident. The care plan should be the central focus for on-going documentation of the residents care, condition, and needs.

(F279) The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be provided to attain or maintain the resident’s highest practicable physical, mental and psychosocial well-being; any services that would otherwise be required but are not provided due to the resident’s exercise of rights including the right to refuse treatment. The care plan must reflect intermediate steps for each outcome objectives if identification of those steps will enhance the resident’s ability to meet his/her objectives. Facility staff will use these objectives to monitor resident progress. Facilities may need to prioritize their care plan interventions. This should be noted in the clinical record or on the plan of care.

The care plan must be prepared by an interdisciplinary team that includes the attending physician, a registered nurse with the responsibility for the resident and other appropriate staff and disciplines as determined by the resident’s needs and to the extent practicable the participation of the resident, the residents family or the resident’s legal representative. There should be evidence that the care plan is periodically reviewed by a team of qualified persons after each assessment and as the resident’s status changes.

6.4.1 Timeliness:

(F280) A comprehensive care plan must be completed within 7 days of completion of the comprehensive assessment. Completion or updating of the care plan should follow the comprehensive assessment since the assessment provides the foundation or analysis of a problem resulting in the goals and interventions on the care plan. The care plan is reviewed and updated after each scheduled comprehensive assessment – admission, quarterly reviews, annually, and with a significant change in condition.

6.4.2 Care Conference:

(F280) In completion of the care plan, the professional disciplines must work together to provide the greatest benefit to the resident. The mechanics of how the interdisciplinary team meets its responsibilities in developing an interdisciplinary care plan (e.g. a face-to –face meeting, teleconference, written communication) is at the discretion of the facility. The facility should encourage residents, surrogates, and representatives to participate in care planning including encouraging attendance at care planning conferences.

6.4.3 Admission/Interim Care Plan:

Upon admission, a brief initial care plan should be developed to carry through until the resident’s comprehensive assessment and care plan have been developed. The care plan should address the primary reason for admission and treatment and the resident’s most immediate care needs. Usually the plan includes clinical and/or rehab needs and nutritional needs.

6.4.4 Integrating Acute Problems into the Care Plan:

When temporary or acute problems arise, the facility documents an assessment of the problem and implements a plan. It is at the facilities discretion on how the acute problem is incorporated into the care plan. The acute problem can be incorporated into the comprehensive care plan or could be documented on a separate acute or temporary care plan form. If an acute care plan is used, there must be documentation of the problem, interventions and conclusion.

6.4.5 Timeliness of Completion of Care Plan:

The comprehensive care plan should be in the medical record within 7 days after completion of the comprehensive assessment. For example, if the care conference is held 7 days after the completion of the comprehensive assessment, the updated care plan would be on the record or available for staff to use on that day.

6.4.6 Authenticating Changes to Care Plan:

Since the care plan is a key document that should be kept up to date at all times, changes are frequently made. Each time there is a change made on the care plan, staff making the change must follow proper legal documentation guidelines and authenticate and date the entry. This includes making a new entry, changing, or discontinuing an entry.

6.5 Narrative Charting and Summaries:

6.5.1 Admission/Readmission Note:

It is a standard of practice to write a note at the time of admission that documents the date and time of admission, how transported, the reason for admission, and the resident’s condition. State regulations may have specific requirements for admission documentation and the time frame for completion.

6.5.2 Content of Narrative Charting:

A complete record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual, has adequate plans of care and provides sufficient documentation of the effects of the care provided. Documentation should provide a picture of the resident’s, including response to treatment, change in condition and changes in treatment. Good practice indicates that for functional and behavioral objectives the clinical record should document change toward achieving care plan goals.

6.5.3 Monthly Summary Charting:

Federal regulations do not require the completion of a summary note, however, some states may require a summary per licensure or reimbursement regulations. Typically summary documentation provides a mechanism to provide an update of the resident’s status.

The summary note should be based on the care plan. If there are changes in the resident’s status from the previous summary or not reflected in the care plan, the summary should describe the resident’s status, the reason for the change, and the updates made to the care plan.

If flowsheets or checklists are used, they should contain an area for narrative documentation to supplement the check boxes, all fields should be completed, if a section does not apply the writer should indicate that is not applicable. When using a flowsheet or checklist, the care plan should still be the basis for the documentation. If there is a change from the previous summary or a change not reflected in the care plan, a note should be written explaining the reason for the change and the updates made to the care plan.

The use of a monthly summary note or flowsheet should not preclude staff from maintaining documentation throughout the month that reflects any changes in condition or status.

6.5.4 Integrated vs. Disciplinary Progress Notes:

6.6 Medicare Documentation:

Medicare documentation must provide an accurate, timely and complete picture of the skilled nursing or therapy needs of the resident. Documentation must justify the clinical reasons and medical necessity for Medicare part A coverage, the skilled services being delivered, and the on-going need for coverage. Documentation along with data gathered from observation and interviews should support the MDS used to determine the Resource Utilization Group (RUG payment level) for the Medicare recipient. The medical record must also support the ancillary services provided to the resident and billed to Medicare by documenting that the services were both delivered and medically necessary.

Note: Some Fiscal Intermediaries (FI) and other payers may have specific local policies pertaining to MDS and other supporting documentation, content and format. When developing documentation systems for Medicare, check with your FI to determine any specific requirements.

6.6.1 Skilled Nursing/Therapy Charting:

The medical record must prove that the resident needed and received skilled services on a daily basis (either nursing or therapy). Medicare charting may be more frequent if necessitated by the resident’s condition. The content of the documentation is specific to the clinical reasons for coverage and services delivered and should be objective and measurable. Medicare worksheets can be helpful in focusing charting to the specific service delivered, related clinical issues, and the resident’s response to care. When therapy services are justifying Medicare coverage, nursing documentation should be consistent with therapy documentation addressing how skills learned in therapy are applied on the nursing unit.

The methods for charting can vary based on the reason for Medicare coverage and the services delivered – documentation can be written narratively, captured on flow records or graphics, charting by exception, through structured notes like SOAP, etc.

In addition to documenting daily skilled services, the medical record should also contain documentation supporting the reason for coverage/non-coverage.

6.6.2 Supporting Documentation for the MDS:

Since the MDS is the basis for determining the payment/RUG class, the medical record documentation should support the answers on the MDS within the time frame established by the assessment reference date.

Note: Some case-mix states will stipulate the specific source document that is allowable in supporting the MDS data and/or additional State specific documentation requirements.The following are types of supporting documentation for the MDS

The following are examples of types of supporting documentation for the MDS.

6.6.3 Therapy Treatment Time:

The individual and group therapy treatment minutes for each resident must be documented in the medical record for all dates in which services were delivered. The treatment minute documentation is then used to complete and support the MDS and RUG level. In addition to treatment time, the RAI manual requires that the physician order must include a statement of the frequency, duration, and scope of treatment.

6.6.4 ADL Charting:

The ADL section of the MDS has an impact on all RUG payment categories for Medicare. The documentation in the medical record should provide support for the scoring on the MDS along with observation and interviews.. A facility may utilize ADL charting tocollect information from all three shifts during the 7 day observation period. If the staff member assessing the ADL status and completing the MDS disagrees with the supporting documentation, a clarification note can be written documenting the rationale for the ADL scoring on the MDS.

6.6.5 Mood and Behavior Documentation:

Mood and possibly behavior scoring on the MDS can impact the Medicare RUG payment category. Because these sections on the MDS requires the reporting of the frequency of the mood or behavior problem, the medical record should provide supporting documentation which quantifies the frequency reported.

6.6.6 Hospital Documentation:

Certain services provided in the hospital are documented on the MDS and will impact the RUG class/payment category. It is important to obtain supporting documentation from the hospital to justify the MDS. A preadmission assessment that captures hospital services and dates of delivery could also be used to support the MDS. When used in this manner, the preadmission assessment should be considered part of the resident’s permanent record and meet the legal documentation standards.

6.6.7 Medicare Certification/Recertification:

Each resident on Medicare must have a Medicare part A certification/recertification completed and signed by a physician knowledgeable of the residents care and treatment. The certification/recertification should include the reason for Medicare coverage and skilled services delivered. Certifications are required upon admission, on day 14, and then every 30 days thereafter while the resident continues to be Medicare part A

6.7 Rehabilitative Therapy Documentation – (On Hold)

6.8 Physician Documentation:

6.8.1 Physician Progress Notes:

(F386) Progress notes must be written, signed and dated with each visit (at least every 30 days for the first 90 days after admission, and at least once every 60 days thereafter). Progress notes should contain information pertaining to the following issues:

• Each physician visit should include an evaluation of the resident’s condition, treatment and a review of, and a decision about, the continued appropriateness off the resident’s condition and current medical regime.
• Progress notes should reflect the continuity of care in maintaining or improving a resident’s mental and physical functioning status.
• Progress notes should indicate the resident’s progress or problems in maintaining or improving their mental and physical functioning status.
• Progress notes identify primary risk factors and causal factors contributing to clinical conditions, functional decline, deterioration or potential for, and lack of improvement and whether avoidable or unavoidable.
• Progress notes clinically validate need for medical intervention or justification for decisions regarding care.
• The physician should review the resident’s total program of care, including medications and treatments at each visit.

6.8.2 Dictated Progress Notes: