Hospice compliance has quickly followed the CMS focus on Home Health in recent years. It’s now our turn to be in the spotlight. Are you ready?
Defensible documentation isn’t about writing lengthy notes or crafting eloquent sentences-it’s about proving the necessity and impact of the care provided, especially under the scrutiny of an outside auditor. The timeless adage, “Each note stands alone,” holds truer now than ever before. As clinicians, we’ve been taught: If it wasn’t documented, it wasn’t done. However, in today’s world of electronic health records (EHR), the shift toward efficiency has created a troubling trend: boxes are diligently checked, but comment sections are left blank.
Checking a box for “symptoms managed” or “no complaints” won’t hold up in court or satisfy an audit when care is questioned. For example, if you check “shortness of breath” without additional explanation, you’ll find it nearly impossible to defend your actions 5-10 years later when called to a hearing. Every box checked must include context-use the comment sections to describe what you observe, the actions taken, and their outcomes.
Why Documentation Matters
Hospice care operates under Medicare’s Conditions of Participation (CoPs), which dictate the standards required for reimbursement. Participation goes beyond simply checking boxes. It requires a clear account of what you did, why it mattered, and how the patient participated in their care. Insufficient documentation is a leading cause of claim denials.
Consider the following:
- What is your professional clinical opinion?
- How is the patient actively participating in their care?
- Is the Plan of Care (POC) appropriate? If so, for whom and why?
Auditors need to see the patient’s story in your notes. Use the patient’s words to illustrate their progress and goals. For example, instead of “I want to walk with a steady gait to the kitchen,” which sounds like a clinician’s phrasing, document the patient’s authentic words: “I want to catch my breath when I walk to the kitchen.” For hospice patients, their words often reflect their reality: “This pain is killing me,” or “I just want to sleep and not wake up.”
Every note must demonstrate why the care you’re providing is essential, specific, and tailored to the patient’s needs and terminal diagnosis. Avoid vague phrases or generic interventions; instead, paint a vivid picture of the patient’s condition, their progress, and the goals you’re working toward together.
Avoid These Common Pitfalls
- Generic Assessments: Simply documenting “short of breath” or “vital signs stable” doesn’t provide a clear picture of the patient’s condition.
- Copy-Paste POC Goals: A plan of care must be meaningful and measurable. Avoid using identical interventions and goals for every patient; tailor them to each individual’s needs and situation.
- Disconnected Documentation: Writing notes late at night or long after a visit often results in sterile and incomplete entries. Document in the home whenever possible to ensure accuracy and patient engagement.
Example of Defensible Charting
- Plan of Care:
Patient Bob will remain comfortable with oxygen 2-3 L continuously. The nurse will monitor for increased demand or anxiety related to shortness of breath. - Goal:
Patient Bob states: “I want to breathe easier and not feel panicked.” - Admission Assessment (COPD):
The patient is short of breath, evidenced by an increased respiratory rate of 40. Three weeks ago, the patient could speak without pausing to catch their breath. On admission, using oxygen 2-3 L continuously. One month ago, oxygen was used PRN. A recent respiratory infection has necessitated continuous oxygen use. The patient remains short of breath, even at rest. Upon removal of oxygen, pulse oximetry decreased to 85% within two minutes, and respirations increased to 50 with visible anxiety. Oxygen was reinstated, returning the patient to baseline.
This detailed documentation provides a clear picture of the patient’s condition and the rationale for the care provided. It is specific, measurable, and focused on the patient’s needs and goals.
Tailor Your Care to the Patient
Hospice care is dynamic. For example, if a patient admitted with COPD initially requires intensive monitoring, your visit frequency should reflect this. Start with higher frequencies (e.g., 3x/week), taper down as symptoms stabilize, and increase again if the patient’s condition worsens. A static frequency of 1x/week, regardless of the patient’s condition, fails to meet the Cops or reflect the reality of hospice care.
When creating or updating the plan of care:
- Clearly explain why changes were made.
- Resolve unmet goals, document why they couldn’t be achieved and set new, attainable goals.
- Personalize the plan with patient and caregiver names to make it specific and relatable.
The Challenge for Clinicians
We challenge you to document at least 50% of your notes in the home while engaging the patient in the process. Editing and refining your notes after- hours is far easier than trying to recall the details of a visit hours later.
Take credit for the incredible work you do every day. Your documentation should reflect the positive impact you’re making on your patients’ lives.