Easy Techniques You Can Use NOW to Get your Nurses to Document Skilled Need

You want to know a secret? I never learned to document a nursing note in nursing school. In fact, I didn't even know what 'skilled care' was when I graduated. I'm willing to bet that most of you didn't either! It's not that I didn't go to a great school, it just wasn't as important as learning to assess patients, start IVs, prime a pump, do wound care or learn about all the different body systems. Whew! I'm glad I got that off my chest.

So how can we get our nurses to document skilled services? The first thing we need to do is teach them what 'skilled' means. And I don't mean tell them the definition from the CMS or the RAI manual. What does it really mean? This should be part of their orientation process, because again, I'm betting no one has taught them this before. Once they have an understanding of their role in the patient's skilled needs, the nurse notes will start to flow more easily for them.

What is Skilled Need?

Let's take a look at CMS's definition of skilled need and then tear it apart to get a clear picture of what the floor nurse needs to know about the skilled services they provide.

The Medicare Benefit Policy Manual, Chapter 8 says:

Skilled nursing and/or skilled rehabilitation services are those services, furnished pursuant to physician orders, that:

• Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists; and

• Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.

The same manual later describes: Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a “daily basis,” i.e., on essentially a 7-days-a- week basis.

Key takeaways for the skilled floor nurse:

1. It has to be done by the nurse

2. Safety of the medically desired result is to be determined by the nurse

3. It must be evidenced that it is required and done on a daily basis

*If the nurse cannot delegate the task to a CNA or Med Tech it's probably a skilled service*

Once the nurses understand these 3 components of the definition they will understand the importance of their documentation. It would also be a good time to remind them that their documentation is THE critical element for getting paid from insurance companies and Medicare.

Examples

1. An 81-year-old woman who is aphasic and confused, suffers from hemiplegia, congestive heart failure, and atrial fibrillation, has suffered a cerebrovascular accident, is incontinent, has a Stage 1 decubitus ulcer, and is unable to communicate and make her needs known. Even though no specific service provided is skilled, the patient’s condition requires daily skilled nursing involvement to manage a plan for the total care needed, to observe the patient’s progress, and to evaluate the need for changes in the treatment plan.

In this particular scenario there is not a specific skilled need, however, a nurse must assess her Stage 1 pressure area and advise the CNAs to take extra care of the area or else it could deteriorate into a much worse wound. The nurse also evaluates her lung sounds and checks for edema daily and has to elevate the patients legs. Her A-fib puts her at greater risk for further complications so the nurse evaluated vital signs and meds and labs must be more closely monitored. The nurse must also increase her observation of the status of the patient's cognition and physical functioning due to the CVA, confusion and aphasia. Can you see how documenting these interventions in a few short sentences that what the nurse did for this patient qualifies as a skilled need?

2. An aged patient is recovering from pneumonia, is lethargic, is disoriented, has residual chest congestion, and is confined to bed as a result of his debilitated condition. To decrease the chest congestion, the physician has prescribed frequent changes in position, coughing, and deep breathing. While the residual chest congestion alone would not represent a high risk factor, the patient’s immobility and confusion represent complicating factors which, when coupled with the chest congestion, could create high probability of a relapse. In this situation, skilled overseeing of the nonskilled services would be reasonable and necessary, pending the elimination of the chest congestion, to assure the patient’s medical safety.

In this scenario we have a debilitated patient who is no longer receiving treatment for pneumonia.

The nurse is prompting and guiding the patient to ensure coughing and deep breathing is done correctly. The nurse also assesses lung sounds, and evaluates vital signs until the chest congestion is resolved. The nurse also monitors vital signs and checks for signs and symptoms of a relapse for the pneumonia and reports any changes to the MD. These simple acts can prevent re-hospitalization of a frail patient, but if it isn't documented daily a MAC or insurance company would likely to take back money in the event of an audit.

Key Takeaways

These 4 items will meet skilled qualifications when documented at least daily:

• What the nurse does to prevent re-hospitalization

• What the nurse does that changes the plan of care or treatment goals

• What the nurse did for a decline in condition

• What the nurse did that resulted in an improvement in condition

How to Document Skilled Need

Now that the nurses understand what skilled care really is, it's time to break down the steps for creating a quality note that depicts the care provided without spending too much valuable time.

1. Start with the end in mind

   1. At the end of your shift you want to be able to state what you did for your patients and how they responded or any changes (for better or worse) that they had. So be thinking about this each time you interact with your patients.

2. Takes notes throughout the day of what you did for each patient

   1. Skilled care is essentially about what the nurses provided for their patients. Take notes when you provide education, reminders, assessed, evaluated, and care items that are skilled in nature but overlooked because it has become routine.

3. Keep a list of action items that can be referred to when writing your note

   1. Assisted, adjusted, auscultated, palpated are all things nurses do on a daily basis for their patients that can be skilled in nature yet they don't take credit for it because they neglect to write it down.

4. Use the check lists in your EMR's nurses notes to guide your narrative

   1. Those fancy EMR's with checklists for each body system are great! But it's not the finished product. These tools are a guidance system to help write a great, skilled nurses note. Any check boxes that fall outside the normal parameters will need to be expanded upon in a narrative note. This is where you get to refer to the notes you took throughout the shift to explain the care you provided.

Phrases to Avoid

• Patient tolerated treatment well

• Continue with POC

• Patient remains stable

• Resting quietly with eyes closed

Instead document

• Patient reported no discomfort during wound care.

• Will continue to monitor wound and report changes to the MD

• Patient remains free from signs/symptoms of infection

• Patient does not display signs/symptoms of pain, SOB, or anxiety

See how. a little bit of knowledge can change the entire dialogue of a nurses note? With a shift in thought process it becomes easier to document the interventions done by the nurse instead of describing what the patient does. It takes a little investment up front to teach and a little practice by the nurses, but it will serve everyone well!

MDS Solutions HQ

Do you want to take your facility to the next level? Let MDS Solutions HQ show you where your opportunities are. Whether it’s improved quality of care, better survey outcomes or if revenue is your focus it all begins with the MDS. I specialize in training MDS nurses in the RAI process, training floor nurses to document skilled need, educating revenue capture through the PDPM process, analyzing and creating action plans for QM and 5 star success.

Contact me at:

https://mdssolutionshq.wixsite.com/my-site

MDSSolutionsHQ@gmail.com or 404-309-3013

Vanessa Tyscka founded MDS Solutions HQ after 25+ years of service focused on serving Skilled Nursing Facilities and their residents. During her career she has worked as a Senior Reimbursement Specialist, Regional MDS Director, MDS Coordinator, DON, ADON, Unit Manager, RN, LPN, and CNA. She has worked for large and medium sized corporations and also has consulting experience in standalone and small organizations. She brings a passion of caring and expert knowledge to every facility she visits. To learn more about Vanessa’s experience and services check out her website or visit her LinkedIn page: www.linkedin.com/in/vanessatysckarn

When Vanessa isn’t working she enjoys cooking things she’s never tried before and spending time in the mountains or on a beach.