HOME HEALTH ASSESSMENT CRITERIA HOME HEALTH

75 Checklists for Skilled Nursing DocumentationBarbara Acello, MS, RNLynn Riddle Brown, RN, BSN, CRNI, COS-CInitial assessments can be tricky—without proper documentation, home health providers couldlose earned income or experience payment delays, and publicly reported quality outcomes affected by poor assessment documentation could negatively impact an agency’s reputation.All of the book’s 75-plus checklists are also available electronically with purchase, facilitatingagencywide use and letting home health clinicians and field staff easily access content no m atterwhere they are.THIS BOOK WILL HELP HOMECARE PROFESSIONALS: Easily refer to checklists, organized by condition, to properly assess a new patient Download and integrate checklists for use in any agency’s system Obtain helpful guidance on assessment documentation as it relates to regulatory compliance Appropriately collect data for coding and establish assessment skill proficiencyACELLO BROWNEnsure that no condition or symptom is overlooked and documentation is as accurate as p ossiblewith Home Health Assessment Criteria: 75 Checklists for Skilled Nursing D ocumentation.This indispensable resource provides the ultimate blueprint for accurately assessing patients’ symptoms and conditions to ensure regulatory compliance and proper payment. It will help agencies deliver more accurate assessments and thorough documentation, create better careplans and improve patient outcomes, prepare for surveys, and ensure accurate OASIS reporting.HOME HEALTH ASSESSMENT CRITERIAHOME HEALTHASSESSMENT CRITERIAHOME HEALTHASSESSMENTCRITERIA75 Checklists for SkilledNursing DocumentationHHAC7529134 Home Health Assesment Book Cover Front and Back.indd 1a divisionof BLR100 Winners Circle, Suite 300Brentwood, TN 37027www.hcmarketplace.comBarbara Acello, MS, RNLynn Riddle Brown, RN, BSN, CRNI, COS -C5/21/15 12:57 PM

Home Health Assessment Criteria: 75 Checklists for Skilled Nursing Documentation is published by HCPro, a division of BLR.Copyright 2015 HCPro, a division of BLRAll rights reserved. Printed in the United States of America. 5 4 3 2 1ISBN: 978-1-55645-717-3No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, or theCopyright 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, AuthorLynn Riddle Brown, RN, BSN, CRNI, COS-C, AuthorTami Swartz, EditorErin Callahan, Senior Director, ProductElizabeth Petersen, Vice PresidentMatt Sharpe, Production SupervisorVincent Skyers, Design Services DirectorVicki McMahan, Sr. Graphic DesignerMichael McCalip, Layout/Graphic DesignKelly Church, Cover DesignerAdvice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions.Arrangements can be made for quantity discounts. For more information, contact:HCPro100 Winners CircleSuite 300Brentwood, TN 37027Telephone: 800-650-6787 or 781-639-1872Fax: 800-785-9212 Email: customerservice@hcpro.comVisit HCPro online at www.hcpro.com and www.hcmarketplace.com

ContentsAbout the Authors. ixPurpose. xSection 1: Assessment Documentation Guidelines1.1. Medicare Conditions of Participation. 31.2. Determination of Coverage Guidelines. 81.3. Summary of Assessment Documentation Requirements. 141.4. Assessment Documentation for Admission to Agency. 201.5. Case Management and Assessment Documentation. 211.6. Assessment Documentation for Discharge Due to Safety or Noncompliance. 241.7. Start of Care Documentation Guidelines. 261.8. Routine Visit Documentation Guidelines. 311.9. Significant Change in Condition Documentation Guidelines. 351.10. Transfer Documentation Guidelines. 391.11. Resumption of Care Documentation Guidelines. 401.12. Recertification Documentation Guidelines.44Contents1.13. Discharge Documentation Guidelines. 48 2015 HCProHome Health Assessment Criteria: 75 Checklists for Skilled Nursing Documentationiii

ContentsSection 2: General Assessment Documentation2.1. Vital Sign Assessment Documentation. 542.2. Pain Assessment Documentation. 572.3. Pain Etiology Assessment Documentation. 592.4. Change in Condition Assessment Documentation. 612.5. Sepsis Assessment Documentation. 652.6. Palliative Care Assessment Documentation. 672.7. Death of a Patient Assessment Documentation. 692.8. Cancer Patient Assessment Documentation. 71Section 3: Neurological Assessment Documentation3.1. Neurological Assessment Documentation. 763.2. Alzheimer’s Disease/Dementia Assessment Documentation. 793.3. Cerebrovascular Accident (CVA) Assessment Documentation. 813.4. Paralysis Assessment Documentation. 883.5. Seizure Assessment Documentation. 913.6. Transient Ischemic Attack (TIA) Assessment Documentation. 98Section 4: Respiratory Assessment Documentation4.1. Respiratory Assessment Documentation. 1014.2. Chronic Obstructive Pulmonary Disease (COPD) Assessment Documentation. 1044.3. Pneumonia/Respiratory Infection Assessment Documentation. 107ivHome Health Assessment Criteria: 75 Checklists for Skilled Nursing Documentation 2015 HCPro

ContentsSection 5: Cardiovascular Assessment Documentation5.1. Cardiovascular Assessment Documentation.1125.2. Angina Pectoris Assessment Documentation.1155.3. Congested Heart Failure (CHF) Assessment Documentation.1185.4. Coronary Artery Bypass Graft Surgery (CABG) Assessment Documentation. 1225.5. Coronary Artery Disease (CAD) Assessment Documentation. 1245.6. Hypertension Assessment Documentation. 1265.7. Myocardial Infarction Assessment Documentation. 1295.8. Orthostatic Hypotension Assessment Documentation. 1315.9. Pacemaker and Defibrillator Assessment Documentation. 133Section 6: Gastrointestinal Assessment Documentation6.1. Gastrointestinal Assessment Documentation. 1376.2. Cirrhosis Assessment Documentation. 1406.3. Crohn’s Disease Assessment Documentation. 1426.4. Hepatitis Assessment Documentation. 1446.5. Peritonitis, Suspected Assessment Documentation. 1486.6. Pseudomembranous Colitis Assessment Documentation. 150 2015 HCProContentsContents6.7. Ulcerative Colitis Assessment Documentation. 151Home Health Assessment Criteria: 75 Checklists for Skilled Nursing Documentationv

ContentsSection 7: Genitourinary Assessment Documentation7.1. Genitourinary Assessment Documentation. 1557.2. Acute Renal Failure Assessment Documentation. 1567.3. Chronic Renal Failure Assessment Documentation. 1587.4. Urinary Tract Infection (UIT) Assessment Documentation. 160Section 8: Integumentary Assessment Documentation8.1. Integumentary Assessment Documentation. 1658.2. Skin Tear Assessment Documentation. 1718.3. Herpes Zoster Assessment Documentation. 1728.4. Leg Ulcer Assessment Documentation. 1738.5. Necrotizing Fasciitis (Streptococcous A) Assessment Documentation. 1778.6. Pressure Ulcer Assessment Documentation. 179Section 9: Musculoskeletal Assessment Documentation9.1. Musculoskeletal Assessment Documentation. 1869.2. Arthritis Assessment Documentation. 1889.3. Compartment Syndrome Assessment Documentation. 1929.4. Fall Assessment Documentation. 1939.5. Fracture Assessment Documentation. 198viHome Health Assessment Criteria: 75 Checklists for Skilled Nursing Documentation 2015 HCPro

ContentsSection 10: Endocrine Assessment Documentation10.1. Endocrine Assessment Documentation.20410.2. Diabetes Assessment Documentation. 207Section 11: Eyes, Ears, Nose, Throat Assessment Documentation11.1. Eyes, Ears, Nose, Throat Assessment Documentation. 21111.2. Dysphagia Assessment Documentation.

and to provide guidelines for the assessment of the homecare patient. It should be used as an aide for identifying needs of the patient for development of the plan of care. Every patient is an individual with . Purpose. x. Home Health Assessment Criteria: 75 Checklists for Skilled Nursing Documentation 2015 HCPro