Tuesday, October 5, 2010

5 hospice documentation tips

Ever wondered what are the most important areas to concentrate on when documenting in a hospice patient's clinical record? Here are a few quick tips that, if followed, can go a long way.
  1. Document the local coverage determinations (LCD) for the hospice diagnosis or general evidence of decline, if the hospice diagnosis is not covered by a disease specific LCD.
  2. Document evidence of decline. Quantify the evidence of decline using timeframes, scales and any tool that can show in detail the decline that is occurring.
  3. Document in detail the symptoms that the patient experiences, specifically related to the hospice diagnosis and quantify the patient's experience. If the patient's symptoms are well controlled, document the measures that are successfully controlling the symptoms.
  4. Document collaboration with the interdisciplinary team regarding arrangements for care, response to changes in the patient's care needs and outcomes of interventions.
  5. Document unplanned care, visits or calls to manage the patient's experience.

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