SOCIAL SERVICES

A QUALITY KEY

PRESENTED BY

Rhonda Anderson, RHIA

President, AHIS

Anderson Health Information Systems, Inc.940 W. 17th Street, Suite B

Santa Ana, CA 92706Tel. 714-558-3887Fax 714-558-13-2

Email office@ahis.net

TOP TEN KEYS TO QUALITY DOCUMENTATION

• KISS – Keep It Simple and Short

• Documentation System – Manual or automated, individualized to patient?

– Does your records include pertinent data and follow the format/content requirements?

• Don’t repeat information from others

• Keep the records/documentation sequential/organized

TOP TEN KEYS -2

• Timely, accurate, legible if manual; date, time entry and signed if automated

• Document completely and identify the patient clearly. Ensure documentations do not look like a “stamp” for all patients.

• Tell how you planned, what you did and the outcome

• Meet both State and Federal regulations

TOP TEN KEYS -3

• Assessments – In the old and the new regulations, assessments are still a part of the planning and delivery of services.

• Accuracy and completeness of assessments mean the resident and the related family/support system information. (Of course consent of the patient is important because without that you really have no resource beyond the patient.)

WHAT IS THE GOAL OF SOCIAL SERVICES?

• MAXIMIZE Support and Adjustment – “Patient and family”– What does that mean to you?

– Have you determined this with your interdisciplinary team?

– Do your policies and procedures reflect this approach?

– Have you included interest in transplant & f/up?

ASSESSMENTS

• Individualized

• Identify the patient’s past

• Disabilities aside from the ESRD issues

• Mental status previously and now

• Language barriers

• Past work life so the IDT can consider how that can be carried into today’s challenges

• Past compliance with food and nutrition

ASSESSMENTS -2

• Family relationship and status• Mental status in the past and currently

observed, i.e., medication side effects and social impact

• Support system, i.e., family, friends, employer• Resources needed, i.e., identification of

transportation, equipment, caregivers, medications

• Etc…etc.-- different for each resident

ASSESSMENTS -3

• Assessment is NOT only initial. It is an ongoing process as you see the patient, participate and assist the patient and family to participate in the treatment planning process.

• The initial assessment does assist with determining some of the immediate needs and barriers.

ASSESSMENT IS KEY!

Initial and ongoing assessment

WHAT ELSE CAN I DO TO IMPACT QUALITY OUTCOMES?

• To name a few:– Education

– Counseling

– Offering options

– Working with the I.D.T which includes the patient, family and support system

• Make certain notes reflect this ongoing assessment and involvement, working with the patient and others

WHAT ELSE CAN I DO -2

• Focus on the behavioral emotional issues and assist with calming that process

• Identify compliance with discussion with patient/family/others

• Anticipate problems and coordinate with I.D.T.

• Communicate and encourage participation in the plan of care

WHAT ELSE CAN I DO -3

• Evaluate and provide ongoing education about:– The dialysis process

– The family, social/work aspects and challenges

– Awareness of the emotional toll

– Psychosocial goals and life’s goals within the context of the dialysis needs

– Follow up on transplant interest

– Medication understanding of issues/w/nursing

WHAT ELSE CAN I DO -4

• Feedback from the patient on understanding of:– Dialysis

– Impact

– Medications side effects on emotions

– Sleep disturbance and approaches

– Etc.

WHAT ELSE CAN I DO -5

• Hospice services when that is applicable

• Emergency preparedness and travel support

• Teamwork!

WHAT IS THE OUTCOME?

• How do you measure what you have completed?

• A good job working with the patient, in that goals are met, if not met the I.D.T. is working with the patient.

WHAT IS THE OUTCOME? -2

• Document the activities and actions– on a regularly scheduled basis, quarterly is a

minimum; but not the expected– As activities and actions occur

COMPLIANCE WITH SURVEY STANDARDS

• What do surveyors expect?– Assessment – focus on the obvious – complete

assessment!!

– Care Planning – plan the findings from the I.D.T. assessment – involvement of the patient and dealing with the outcomes both positive and those where goals are not met

– Ongoing documentation of assessing the patient and follow up.

COMPLIANCE WITH SURVEY STANDARDS -2

• What do surveyors expect? (cont.)– Services supports – documented– Emotional and behavioral assessed and

addressed not only in some cases with the patient, their family and staff providing the dialysis services.

IT IS NOT NEW

• MAXIMIZE PATIENT COMPLIANCE TO TREATMENT!!!

• And you do it so well– Now document all those good services you

provide and show the outcome.

THANK YOU FOR ATTENDING