Through the challenges of the pandemic, charting quality may have taken a backseat to other priorities during times of staffing shortages and outbreaks. However, claims for services related to COVID-19 care are vulnerable to medical review. Consider these best practices and case examples in skilled nursing documentation performance improvement efforts:
Nursing Skilled Services
Whether the diagnosis is COVID-19 pneumonia, J12.89, or another primary diagnosis, daily skilled nursing is based on the skilled need that can only be met by the special skills of a licensed nurse, and the special treatment being provided to the resident, seven days per week, by a licensed nurse. A particular diagnosis or charting that the resident is “skilled” does not stand alone to meet the definition of a skilled service. Documentation must clearly demonstrate the specific skilled need and medical necessity of services along with the resident’s clinical status and response to treatment. Moreover, if utilizing a standard form for skilled documentation (e.g., check off form), the need for and administration of the skilled nursing condition or service may need to be reflected beyond this generalized format to reflect patient-centered skilled services through a supplemental narrative note.
COVID-19 Assessment & Documentation Guidelines
Daily skilled documentation should address specific patient assessment findings as well as body systems that may be affected by specific diseases and conditions. The following COVID-19 documentation considerations and respiratory assessment are guidelines for nursing documentation. Additional documentation may be required based on the individual resident’s comorbidities and clinical condition.
|Documentation Considerations||Respiratory Assessment|
|S/S Hypoxemia/O2 Sat||Amount of O2 delivered*|
|Lung sounds||Lung sounds|
|Dyspnea /SOB*/ Cough||Productive cough, sputum production|
|Congestion/runny nose||Respiration depth and rate|
|Headache||Presence of chest pain|
|Sore throat||Vital signs including oxygen saturation|
|Myalgia/Arthralgia||Sternal retraction, distended neck veins|
|Loss of Taste/smell|
|Weight loss*/Loss of appetite/decreased intake|
|Confusion/change in orientation|
|Isolation type (AND in room alone or cohorting) *|
|Pain / Abdominal Pain|
|Care plan updates|
|Any changes in condition|
Response to Pharmacological & Nursing Interventions
|Labs/Diagnostic testing performed and results (including pneumonia*)|
|Obstacles to discharge to a lesser level of care|
|Progress toward safe discharge transition plan|
*Fever, SOB lying flat, vomiting, weight loss, isolation, respiratory therapy, pneumonia, and O2 are PDPM and/or case mix qualifiers (state-specific dependent) for nursing classifications.
Documentation Case Examples
- S has tested positive for COVID-19+. His temperature was 100.1 & pulse 96. Within 1 hour of administration of Acetaminophen, temperature reduced to 98.2, and pulse to 80. Acetaminophen alleviated sore throat and headache. Mr. S has an occasional non-productive cough. Lung sounds are clear with O2 Sat=96%. Mr. S has had decreased intake. When questioned about decreased intake and fatigue over the last 2 days, he relays that he has new loss of taste and has had nausea that began at breakfast today and also noted fatigue. Encouraged to increase fluid intake to prevent dehydration. Referral was made to RD due to decreased intake. Zofran was administered due to nausea.
In this example, skilled observation is needed to observe & assess: vital signs, respiratory status, pain, GI status, nutritional status, hydration status and ADL status.
- J is skilled r/t COVID-19+. She has been asymptomatic except now having decreased fluid intake. Her BP is typically 120’s/80’s.
8 am: Mrs. J BP this am was to be 96/66 with electronic wrist cuff. Manual check=90/62. Dr. W notified of BP and decreased fluid intake. New orders received to hold Metoprolol 25 mg this am, re-check BP in 1 hr. & parameters to hold if SBP is less than 100 & call MD. Also ordered to increase PO intake & re-check BP in 1 hr.& BMP in 2 days. Parameters added to Metoprolol order & also added to MAR to offer an additional 240 ml of fluid with each med pass. Lab requisition for BMP sent to Express Lab. 9:05 am: Mrs. J drank 360 ml of water. Manual BP re-check=100/64.
With this example, Mrs. Jones had a change in condition with decreased BP. Decreased BP & intake may indicate medical instability. Modification of treatment included holding BP medication & implementing SBP parameters. Initiation of additional orders included increasing PO intake, re-check of BP & lab. Future complications with BP abnormalities or development of an acute episode of dehydration/fluid & fluid volume imbalance are sufficient to justify the need for continued skilled observation and assessment.
- B is recovering from COVID-19 pneumonia. He is experiencing confusion & disorientation. He has residual chest congestion and is chairfast as a result of his debilitating condition. To decrease the congestion, the MD has ordered frequent changes in position, coughing, and deep breathing.
8:15 pm Mr. B is more alert this shift to person, staff’s faces & place. Lung sounds with wheeze to left lung base pre-nebulizer treatment & cleared post-nebulizer treatment. Cough is productive with thin, white sputum. Turned and repositioned q hour while in bed and coughing & deep breathing completed after each repositioning. Mr. B is able to follow deep breathing instructions with nurse demonstrating as he performs.
This example notes Mr. Brown’s chest congestion, decreased mobility, and impaired cognition that could represent risk factors with a high probability of exacerbation or further complications. Skilled oversight of the non-skilled services would be reasonable and necessary, pending the elimination of chest congestion & lung sounds to be clear, to assure the resident’s medical safety.
- G is a frail 87-year-old woman that was hospitalized for pneumonia. DC Summary notes that infection has resolved. However, she is now having inadequate nutritional intake and weight loss with possible need for feeding tube. Mrs. G was transferred to the SNF.
Mrs. Grey will consume 75% of meals and drink 1800 ml/day.
Mrs. Grey will not develop signs and symptoms of dehydration.
Mrs. Grey’s pressure ulcer will heal in 2 weeks.
1 pm Mrs. Grey has eaten 25% of breakfast & 50% at lunch. Staff must cue frequently to take bites and drink fluids. Offered Ensure & she states that Strawberry is her favorite. She drank 480 ml this shift with meals and med pass and 240 ml of Ensure. Mucous membranes are pink and moist.
8:30 pm CNA alerted that Mrs. Grey has open areas to her bottom. Two Stage 2 pressure areas to right and left buttock observed. Right buttock measures 1×1.3 cm and left buttock measures 1.2×1.5cm. Wound beds are reddened with no odor or drainage. MD notified with new orders for treatment for right and left buttock and RD consult.
This example demonstrates that skilled observation and monitoring are necessary to assess fluid and nutrient intake and assistance with feeding with possible need for feeding tube. Observation and monitoring by skilled nursing personnel of the patient’s oral intake are required to prevent dehydration and assure adequate nutrition. The medical documentation must describe the skilled services that require the involvement of nursing personnel to promote the patient’s recovery and medical safety in view of the patient’s overall condition. Since Mrs. Grey developed pressure ulcers, her care plan requires the addition of this problem and goal.
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- Centers for Disease Control and Prevention. (2020, December 22). Symptoms of Coronavirus. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fabout%2Fsymptoms.html
- Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 8. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08pdf.pdf