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Pitfalls of Missing Shortness of Breath Documentation

Chronic conditions and comorbidities are common among both long-term residents and short-term patients in skilled nursing facilities (SNFs). However, when the symptoms from these chronic conditions become part of the resident’s normal routine, they may be under-charted—which could result in inaccuracies in MDS assessments, care plans, Quality Measures, and reimbursement. Consider this scenario of Sally, a long-term care resident with shortness of breath from COPD:


The nurse aide pauses with Sally a few feet in front of her room. Sally is leaning a little heavily on her walker but maintains her balance. With pursed lips, she takes a few more deep breaths and thanks the aide for giving her “a breather.” The aide smiles and nods, expecting Sally to say just those words, which was the daily cue that she was ready to continue the walk into her room. The aide assists Sally with her cares and getting settled into her recliner. The aide does not report the shortness of breath to the nurse, as this occurs daily when walking back from the dining room.


Since the shortness of breath was within the resident’s normal routine, the nurse aide did not report this shortness of breath to the nurse for further assessment. Reporting episodes of shortness of breath, even when they are not abnormal for the resident, contributes to:


1. Improved care planning.

Not assessing the shortness of breath makes it difficult for a nurse to determine if the shortness of breath has worsened over the course of days or weeks. In addition, if the nurse is made aware, a pulse oximeter can be used to measure the oxygen saturation at the point where the resident needs a break, as well as how quickly the numbers return to normal. Assessment of these symptoms may lead to a more efficient and effective care plan—for example, adding a break fifteen steps earlier may prevent a large drop in oxygen saturation and avoid the discomfort Sally experienced when she waited until she needed the breather. The assessment may also uncover other treatable underlying conditions that are contributing to the shortness of breath.

2. Improved quality of care.

Sally may also benefit from a therapy referral. Physical Therapy may be able to work to improve Sally’s breathing and endurance while ambulating and help determine when and if a break is needed. This functional improvement would also improve Sally’s quality of life.

3. Improved Quality Measures.

Residents may find shortness of breath distressing, which may lead to avoiding activities they enjoy, which can in turn decrease quality of life. Shortness of breath can result in a resident triggering Quality Measures for decline in activities. The decline in activity may lead to pressure ulcers, falls, depression, anxiety, or other adverse events—all of which could impact quality outcomes and be reflected in the Quality Measures.


Adequately assessing the root-cause of the shortness of breath and contributing factors can lead to improved care planning that improves quality of life, as well as reflecting the improved care and outcomes in the Quality Measures. However, a lack of documentation to support shortness of breath can also impact Medicare reimbursement. Consider this scenario of Henry, who is on a short-term skilled rehab stay following an elective hip surgery, but also has comorbidity of COPD:


The nurse assists Henry into a sitting position on the side of the bed. He is able to lower his head to the raised mattress as the nurse lefts his legs into the bed. She asks Henry to roll onto his side so she can perform the dressing change to his surgical wound. She starts to lower the head of the bed, but Henry tells her, “Leave the mattress up. I just can’t lay flat anymore—I get too winded.” The nurse leaves the head of bed elevated and performs the dressing change. The wound is clean and approximated. She listens to Henry’s lungs, which are clear bilaterally, and asks if he feels short of breath. Henry denies any shortness of breath. The nurse completes her charting of the dressing change and makes a note that his lungs are clear and that the resident denies any shortness of breath.


Respiratory symptoms are prominent in many components under the Patient-Driven Payment Model (PDPM) for Medicare Part A residents. There are nine different respiratory-related non-therapy ancillary component qualifiers, including a diagnosis of COPD, which achieves two points. The nursing component has seven respiratory-related qualifiers, which includes a diagnosis of COPD with shortness of breath when lying flat—a Special Care High qualifier. In the scenario above, the nurse accurately documented her assessment of Henry’s lungs and his denial of current shortness of breath, but failed to see the value in charting that he asked for the head of the bed to be elevated to facilitate breathing. The RAI User’s Manual clarifies in the coding instructions for J1100C on page J-22 that this behavior is a symptom of shortness of breath that should be charted.


In addition, while the data is not used for PDPM reimbursement, if the resident avoids activity or is unable to engage in an activity due to shortness of breath, this should be captured under J1100A. For example, if a resident is able to ambulate from his room to the dining room but avoids ambulating long distances due to shortness of breath, this would be captured at J1100A. The key here is that nurses need to not only capture episodes of shortness of breath, but also assess and identify the actions the resident takes or avoids to prevent shortness of breath from occurring.


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