Review question below and using your professional experience, provide an answer or related insights in 150 words.
Assuring that the proper documentation is acquired to justify why a patient is on hospice services is essential because it validates the terminal diagnosis and supports the life expectancy of zero to six months if the disease process follows it natural course. Additionally, proper documentation ensures adequate reimbursement from insurance providers such as Medicare and prevents Additional Documentation Request (ADR’s) from insurance carriers which can cause recoupment of funds. My agency is accredited by Joint Commission. It states in our policy that the Director of Nursing (DON) is required to do monthly random chart audits on thirty percent of our active patients’ charts. Chart audits are due on the 15th of every month from the prior month. In the findings for April, it was documented that clinical documentation had untimely filing; there was misuse of clinical abbreviations; charts had incomplete documentation and medication profiles were inaccurate and incomplete. To effect the changes in results retrieved from chart audits additional research is needed to identify the specific variable that can be changed to have a positive impact on the outcome. With the following research question being posed, by doing a fifty percent monthly random chart audit instead of thirty percent, would there be a reduction in deficiency associated with patient charting from the clinical staff. A quantitative approach will be used to answer the research questions on the perceptions of the clinical staff in the hospice care setting regarding the documentation submitted. Data collection will be gained by access to patient documentation and records of patient charts. Supporting evidence is a trustworthy source when researching patient care and if the care that the patient is receiving is effective and efficient. Hospice providers are under great pressure from insurance providers due to cost reductions for services render (Hansen, Martin, & Jones et.al 2015). Face to face services being provided by physicians or nurse practitioners are tools used to ensure patient eligibility and verification of disease progress while on hospice services; thus these tools are instrumental ensuring that the documentation provided by the clinical staff is congruent with the diagnosis the patient has been admitted and treated for (Quinlin, 2019). Lack of parallel documentation will cause a premature discharge of the patient from services or a recoupment of funds to the payor source. It is important that during monthly audits the DON ensures that documentation between both the physician and the clinical staff are similar and evidence is present to support continuation of service and care.
Hansen, A. G., Martin, E., Jones, B. L., & Pomeroy, E. C. (2015). Social Work Assessment
Notes: A Comprehensive Outcomes-Based Hospice Documentation System. Health & Social Work, 40(3), 191-200. doi:10.1093/hsw/hlv033
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