HOME HEALTH ASSESSMENT CRITERIA HOME HEALTH

HOME HEALTH ASSESSMENT

CRITERIA

75 Checklists for Skilled Nursing Documentation

Barbara Acello, MS, RN Lynn Riddle Brown, RN, BSN, CRNI, COS-C

Home Health Assessment Criteria: 75 Checklists for Skilled Nursing Documentation is published by HCPro, a division of BLR. Copyright ? 2015 HCPro, a division of BLR All rights reserved. Printed in the United States of America. 5 4 3 2 1 ISBN: 978-1-55645-717-3 No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, or the Copyright Clearance Center (978-750-8400). Please notify us immediately if you have received an unauthorized copy. HCPro provides information resources for the healthcare industry. HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.

Barbara Acello, MS, RN, Author Lynn Riddle Brown, RN, BSN, CRNI, COS-C, Author Tami Swartz, Editor Erin Callahan, Senior Director, Product Elizabeth Petersen, Vice President Matt Sharpe, Production Supervisor Vincent Skyers, Design Services Director Vicki McMahan, Sr. Graphic Designer Michael McCalip, Layout/Graphic Design Kelly Church, Cover Designer

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Contents

About the Authors..................................................................................................................................................... ix Purpose....................................................................................................................................................................... x

Section 1: Assessment Documentation Guidelines

1.1. Medicare Conditions of Participation.................................................................................................................. 3 1.2. Determination of Coverage Guidelines............................................................................................................... 8 1.3. Summary of Assessment Documentation Requirements.................................................................................. 14 1.4. Assessment Documentation for Admission to Agency..................................................................................... 20 1.5. Case Management and Assessment Documentation....................................................................................... 21 1.6. Assessment Documentation for Discharge Due to Safety or Noncompliance................................................. 24 1.7. Start of Care Documentation Guidelines........................................................................................................... 26 1.8. Routine Visit Documentation Guidelines........................................................................................................... 31 1.9. Significant Change in Condition Documentation Guidelines............................................................................ 35 1.10. Transfer Documentation Guidelines................................................................................................................. 39 1.11. Resumption of Care Documentation Guidelines.............................................................................................. 40 1.12. Recertification Documentation Guidelines......................................................................................................44 1.13. Discharge Documentation Guidelines.............................................................................................................. 48

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Section 2: General Assessment Documentation

2.1. Vital Sign Assessment Documentation............................................................................................................. 54 2.2. Pain Assessment Documentation..................................................................................................................... 57 2.3. Pain Etiology Assessment Documentation....................................................................................................... 59 2.4. Change in Condition Assessment Documentation............................................................................................ 61 2.5. Sepsis Assessment Documentation.................................................................................................................. 65 2.6. Palliative Care Assessment Documentation..................................................................................................... 67 2.7. Death of a Patient Assessment Documentation............................................................................................... 69 2.8. Cancer Patient Assessment Documentation.................................................................................................... 71

Section 3: Neurological Assessment Documentation

3.1. Neurological Assessment Documentation........................................................................................................ 76 3.2. Alzheimer's Disease/Dementia Assessment Documentation.......................................................................... 79 3.3. Cerebrovascular Accident (CVA) Assessment Documentation......................................................................... 81 3.4. Paralysis Assessment Documentation.............................................................................................................. 88 3.5. Seizure Assessment Documentation................................................................................................................ 91 3.6. Transient Ischemic Attack (TIA) Assessment Documentation.......................................................................... 98

Section 4: Respiratory Assessment Documentation

4.1. Respiratory Assessment Documentation........................................................................................................ 101 4.2. Chronic Obstructive Pulmonary Disease (COPD) Assessment Documentation.............................................. 104 4.3. Pneumonia/Respiratory Infection Assessment Documentation..................................................................... 107

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Section 5: Cardiovascular Assessment Documentation

5.1. Cardiovascular Assessment Documentation....................................................................................................112 5.2. Angina Pectoris Assessment Documentation..................................................................................................115 5.3. Congested Heart Failure (CHF) Assessment Documentation..........................................................................118 5.4. Coronary Artery Bypass Graft Surgery (CABG) Assessment Documentation................................................ 122 5.5. Coronary Artery Disease (CAD) Assessment Documentation........................................................................ 124 5.6. Hypertension Assessment Documentation..................................................................................................... 126 5.7. Myocardial Infarction Assessment Documentation........................................................................................ 129 5.8. Orthostatic Hypotension Assessment Documentation................................................................................... 131 5.9. Pacemaker and Defibrillator Assessment Documentation............................................................................. 133

Section 6: Gastrointestinal Assessment Documentation

6.1. Gastrointestinal Assessment Documentation................................................................................................. 137 6.2. Cirrhosis Assessment Documentation............................................................................................................ 140 6.3. Crohn's Disease Assessment Documentation................................................................................................ 142 6.4. Hepatitis Assessment Documentation............................................................................................................ 144 6.5. Peritonitis, Suspected Assessment Documentation....................................................................................... 148 6.6. Pseudomembranous Colitis Assessment Documentation............................................................................... 150 6.7. Ulcerative Colitis Assessment Documentation............................................................................................... 151

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Section 7: Genitourinary Assessment Documentation

7.1. Genitourinary Assessment Documentation..................................................................................................... 155 7.2. Acute Renal Failure Assessment Documentation........................................................................................... 156 7.3. Chronic Renal Failure Assessment Documentation........................................................................................ 158 7.4. Urinary Tract Infection (UIT) Assessment Documentation............................................................................. 160

Section 8: Integumentary Assessment Documentation

8.1. Integumentary Assessment Documentation................................................................................................... 165 8.2. Skin Tear Assessment Documentation........................................................................................................... 171 8.3. Herpes Zoster Assessment Documentation................................................................................................... 172 8.4. Leg Ulcer Assessment Documentation........................................................................................................... 173 8.5. Necrotizing Fasciitis (Streptococcous A) Assessment Documentation.......................................................... 177 8.6. Pressure Ulcer Assessment Documentation................................................................................................... 179

Section 9: Musculoskeletal Assessment Documentation

9.1. Musculoskeletal Assessment Documentation................................................................................................ 186 9.2. Arthritis Assessment Documentation............................................................................................................. 188 9.3. Compartment Syndrome Assessment Documentation................................................................................... 192 9.4. Fall Assessment Documentation..................................................................................................................... 193 9.5. Fracture Assessment Documentation............................................................................................................. 198

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Section 10: Endocrine Assessment Documentation

10.1. Endocrine Assessment Documentation.........................................................................................................204 10.2. Diabetes Assessment Documentation.......................................................................................................... 207

Section 11: Eyes, Ears, Nose, Throat Assessment Documentation

11.1. Eyes, Ears, Nose, Throat Assessment Documentation.................................................................................. 211 11.2. Dysphagia Assessment Documentation........................................................................................................ 212

Section 12: Hematologic Assessment Documentation

12.1. Hematologic Assessment Documentation..................................................................................................... 215 12.2. Anticoagulant Drug Therapy Assessment Documentation........................................................................... 216 12.3. Deep Vein Thrombosis (DVT) Assessment Documentation.......................................................................... 219 12.4. HIV Disease and AIDS Assessment Documentation....................................................................................222

Section 13: Nutritional Assessment Documentation

13.1. Nutritional Assessment Documentation........................................................................................................ 229 13.2. Dehydration Assessment Documentation..................................................................................................... 230 13.3. Electrolyte Imbalances Assessment Documentation................................................................................... 232 13.4. Weight Loss, Cachexia, and Malnutrition Assessment Documentation...................................................... 243

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