Documentation is a critical part of the nurse assessment coordinator’s (NAC’s) role. It helps provide person-centered care, supports clinical decisions, facilitates communication between the nurse and the interdisciplinary team (IDT), prevents many legal issues, and helps with accurate reimbursement.
AANAC’s sister association, the American Association of Directors of Nursing Services (AADNS), recently published the Documentation Toolkit for the Nurse Leader, which contains several helpful tools and resources to make lasting improvements to documentation in skilled nursing facilities (SNFs). Jane Belt, MS, RN QCP, RAC-MT, RAC-MTA, curriculum development specialist for AANAC, shares some insights into how NACs and other nurse leaders can use this tool to review their processes and keep at bay those harrowing reminders of “If it wasn’t documented, it wasn’t done.”
Documentation is an essential part of the NAC’s role
“Right now, between the pandemic and the fact that medical reviews are starting to rev up again, what we document is more important than it has ever been, and it’s actually increasing in importance,” says Belt.
NACs contribute significant documentation for their facilities and also rely on the entire interdisciplinary team to contribute their observations and interactions with the resident. The NACs complete assessments and create a record of the resident’s condition through MDS coding. They select diagnoses based on the physician’s documentation, which requires dissecting the medical records and possibly clarifying information with the physician (or physician extender). The process continues as the NACs complete observations and assessments, discuss them with the physician, and oversee the creation of the necessary documentation of those interactions. NACs express what problems, risks, conditions, and personal goals are the key issues for each resident. Then, in collaboration with the resident, the NACs and the IDT develop person-centered, individualized goals and decide what steps or interventions are needed for the resident in the care plan. And finally, the staff must document what they did for the resident and how the resident responded in the medical record.
Belt elaborates on how the AADNS Documentation Toolkit can help NACs ask the right questions to improve their documentation throughout the nursing process. “The toolkit takes the nursing process that NACs are familiar with and helps walk them through common questions regarding documentation like ‘What do I need to document at each stage of the nursing process? Why is that information important? How can I tell this resident’s story? Why am I writing this note?’”
The nursing process, clinical condition guides, and quality nurses’ notes
In the Documentation Toolkit, there are multiple clinical condition documentation guides covering everything from behavioral expressions to dehydration to tracheostomy care. Belt explains further how these guides can help: “The clinical condition documentation guides are terrific. One of the difficult parts for nurses is figuring out, ‘What do I need to document for a resident with an acute change in condition? Or a mental status change? Infection? Daily wound care? And here it is! It is laid out for you here in easy documentation guides. Some of them you can keep in your pocket; some of them can be laminated and be available wherever you and the other nurses are documenting.”
Belt explains how each guide works. “The clinical condition documentation guides are broken down into steps that we all know as nurses. We know that nursing documentation is based on assessment, nursing diagnosis, planning (goals, wishes, desired outcomes of the resident), implementation (what are we going to do, what did the physician say), and then we have to evaluate the outcomes (the experience by that resident). The guides cover each one of those areas and give a sample narrative note.”
You can see a sample from the Documentation Toolkit of a clinical condition documentation guide covering an acute change in condition here.
Belt explains that NACs need to be very detailed in their nurses’ notes, and the toolkit helps them do that. “A nurse might sometimes write ‘I took vital signs,’ but that’s not the most important information. What were the vital signs? And as a nurse, what did those vital signs tell you? Is the resident in trouble? Why is the resident moving outside of their normal range for a vital sign? Why does their cognition or the way they are talking seem different?” The toolkit is designed to help ask and answer these questions so that NACs and other nurse leaders can enhance the quality and comprehensiveness of their documentation.
Paying the bills with your words
“Reimbursement is how the facility pays the bills; it’s how a facility survives. Whether we like to think about it or not, the facility does need money to make payroll, to pay for benefits, to pay for insurance. There’s got to be a way to recoup that, and documentation is an essential part of doing so,” explains Belt.
NACs help keep SNFs afloat by creating accurate and complete documentation. And it’s becoming more important than ever, as CMS provided states with the option to collect Patient-Driven Payment Model (PDPM) billing codes to inform future Medicaid reimbursement decisions. CMS notes, “Please confirm with your State Medicaid Agency if your State will be requiring the calculation of the PDPM payment codes on the OBRA assessments when not combined with a 5-day SNF PPS assessment.”
For most circumstances, under PDPM, the documentation is completed on the PPS 5-Day MDS assessment, which has an assessment reference date set within an eight-day window from the start of the Medicare stay. The observations and documentation on this assessment will support MDS coding and determine payment for a resident’s entire Medicare stay. The Documentation Toolkit covers this relationship in greater detail regarding what the NAC must look for in the medical record to code the MDS and how that ties into the PDPM components for reimbursement. Belt says, “The Documentation and PDPM section on pages 80-83 goes into the different PDPM components that relate to the MDS—specifically, the Non-Therapy Ancillaries (NTA) and Nursing components—and is a great resource.”
Documenting the need for skilled services
Another important role of documentation that impacts reimbursement is demonstrating the need for skilled services for Medicare Part A residents. Belt says, “There are still plenty of questions out there about whether a service is skilled and what to document. The number one thing we are required to do when we take in a new Medicare Part A resident is ask, ‘What is making them skilled?’ The service must be so inherently complex and sophisticated that only a licensed nurse or a rehabilitation therapist can perform it. What is it?” In the Documentation Toolkit, there is a great resource called the “Skilled Care Services and Documentation Communication Tool” that walks the nurse through the process of assessing and documenting the need for skilled care services for a resident.
In the Documentation Toolkit, it’s not just reading and looking at charts. Belt exclaims, “There’s Skilled Care Bingo! Who doesn’t like Bingo? We know documentation isn’t the most exciting thing to learn. However, gamification can help with making it more fun. This Bingo game goes over the components of documentation for skilled services, such as when does and doesn’t the documentation meet the requirements and why doesn’t it? Teaching staff about Medicare right now is critical, because many still struggle with it, and this is a fun way to do it!”
Audits and avoiding legal hurdles
“Nurse assessment coordinators and nurse aides are not exempt from legal action due to documentation issues,” says Belt. “If a resident didn’t have a great outcome, attorneys will identify who was involved in that care, and those persons can be mentioned in a lawsuit and called for testimony.”
To avoid lawsuits, NACs and other nurse leaders should be auditing their documentation regularly. The Documentation Toolkit has some great audit tools to help with that, including one called the “Audit Tool: Legal Review Documentation Checklist,” which helps nurses audit specific medical records involved in an incident.
Belt says, “I like the audit tools! If I’m the NAC and I’m coordinating three or four MDS nurses that report to me, how do I evaluate what kind of job they are doing other than just looking at whether we have accurate reimbursement on this assessment? It’s not always about the numbers—it’s also about telling the story. Telling that story to whoever happens to look at the medical record, whether it be a surveyor, a Medicare reviewer, an attorney (we don’t like to think about it, but that’s who looks!). These audit tools will help NACs check out whether the medical record has what it needs. Will it pass the test?” The audit tools in the toolkit cover reviewing documentation for clinical conditions, incidents and other special situations, risk assessments, skilled care, legal review, and EMR/EHR physician’s orders.
There is also a “Dos and Don’ts Tip Sheet” designed to help NACs and other nurse leaders mitigate the risks of poor documentation practices. Belt says, “This dos and don’ts tip sheet is very helpful, with good advice such as ‘document in real time,’ ‘document in chronological order,’ what to do if a late entry needs to be documented, ‘use quotation marks and document exactly what is said,’ ‘stick to the facts,’ and more, and then there’s a whole other list of don’ts. All of them are very valuable—yes, they are things we should know and remember, but it’s always good to have a little mental nudge that asks, ‘Have you thought about this recently?’”
Use this toolkit to train new nurses or provide a refresh
The Documentation Toolkit is a great resource for training staff. Belt says, “Take it to the bedside. If you are trying to help a new nurse, this toolkit can help you explain to them why documentation is so important in long-term care. The documentation guidelines are so easy to follow; you know exactly what you need to chart after reading them. The steps are all there.”
Belt also mentions the documentation guides included in the toolkit can help bridge the gap in knowledge for those who transitioned to long-term care from a different care setting. “The documentation guides are not only about clinical conditions, but also about incidences and special situations. Some of the newer nurses, some that came from acute care and are now trying long-term care, they may have difficulty finding out what we need regarding documentation. These documentation guides can really help with that.”
The toolkit can also be used to teach staff how they can improve documentation about and have better conversations with physicians. Belt says, “There’s a section about using the Situation, Background, Assessment, Recommendation (SBAR) technique on page 56. Maybe you have a physician who says to your leadership, ‘You know, when your nurses call, the only thing I know to do is to give them an order for a medication.’ The SBAR technique is a way for the nurse to gather the needed information to report to the physician so that the physician gets the real story of the resident’s status and is able to articulate what’s useful for their care.”
The SBAR technique can help NACs better communicate with the physician and explain to others what they told the physician. Belt says, “It helps us ask, ‘What did we communicate to the physician? What did the physician say back to us?’ Don’t just write ‘Call the physician’ in the notes. Instead, write about why you called the physician, that you made these assessments or observations of the resident, and this is what the physician asked us to do, watch, observe, or assess. Or they told us to send the resident out to the emergency room.” There is a helpful group education activity to go over the SBAR technique and why it is important on page 57 of the Documentation Toolkit.
In praise of the toolkit’s inclusion of practical application ideas, nurse in-service education, tools, videos, and games, Belt says, “The different sections of this toolkit do a great job linking the nursing process to documentation, and they are very informative on how this process works. Yet, the toolkit takes its usefulness one step further by providing examples of how to apply this process to your everyday tasks. There are so many application ideas, and it really caters to many different learning styles as well—auditory, visual, read/write, or kinesthetic learners—there is something for everybody! It’s a great resource for teaching staff.”
Improve NAC and director of nursing services (DNS) collaboration and communication
Both NACs and DNSs alike can use this toolkit in different ways to look at and understand each other’s role in documentation. NACs should use this toolkit as a stepping off point for a discussion with their DNS about how they can work together to tackle and improve documentation for their facility.
“If I’m the DNS and I’m looking at the documentation, I might need to talk to the NAC about how to work together with the nurses to achieve complete and accurate documentation if it is not being done. We have to work in collaboration, the NAC and the DNS. We are not in separate silos, even though many think we are. Most of the training this toolkit enables could be done together by both the NAC and the DNS, not just one. The DNS can give their side of documentation from an administrative and oversight standpoint, and the NAC can show their perspective as well, such as where to put documentation on the MDS, how it drives Quality Measures, or how it drives survey,” says Belt.
Belt provides an example of how documentation, person-centered care, and collaboration all work together to achieve resident and facility goals: “Many NACs are responsible for care planning, and the one thing that surveyors really look for in the survey process is the care plan. What problems were identified? What were the goals the resident stated that they wanted? What did the resident want? It’s got to be person-centered. How are we going to get that resident to that person-centered goal? How are we going to achieve that? It takes a team to make sure we are providing or delivering the interventions needed to help that resident achieve the goals and to document their progress. And that’s when we succeed—when the resident achieves their goals, the facility achieves its goals because our survey is good, our reimbursement is rightful and good, our Quality Measures are reflective of the quality of care we provide, and our documentation is sound. It all goes together. It isn’t in silos.”
“In my experience as both a director of nursing services and a reimbursement consultant, this is one great tool that I would have loved to have had access to when I was working directly with facility staff. It’s comprehensive; it’s fun; it has great learning activities to do with the staff,” says Belt.
Quick tips on how to use this toolkit:
- Print out the clinical condition documentation guides for pocket use or laminate them and place them where nurses complete documentation.
- Fill out the tools and exercises online or print them out. Use the checkmarks in the tools and look to see if your documentation contains what it should.
- Reuse the audit tools multiple times. The toolkit is interactive, so it can be used over and over.
- Immerse yourself and your team in the different ways to learn about documentation – reading, watching videos, gamification with Bingo. Work with your DNS to schedule in-services to go over documentation best practices.
- Actively remind other staff about best practices by asking CNAs and other members of the IDT questions pertaining to the documentation they are collecting for the MDS, specifically about a resident’s condition.
- Use this toolkit to analyze your current documentation process and make improvements accordingly.
- Check out the many additional resources listed in the toolkit for further learning.
- The table of contents is very detailed and interactive. Click on each section title to navigate quickly and go directly to the page for the needed information. Check out the table of contents and sample content here.
The Documentation Toolkit for the Nurse Leader can be purchased on the AADNS website here.
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