Examples Of Poor Nursing Documentation
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Examples Of Poor Nursing Documentation

Supporting practice through quality 2005
2004 2005 Change Master Projects 1 Kentucky Public Health Leadership Institute Supporting Practice Through Quality Nursing Documentation

Kentucky Public Health Leadership Institute Scholars:

Kathy Fields, MPA, RN, CS Director of Community Health Nursing Cumberland Valley District Health Department

Karen King, RN Community Health Nursing Administrator Clark County District Health Department

Marla Jean Powell, RN Community Health Nursing Supervisor Madison County Health Department

Beverly Aldridge, RN Community Health Nursing Supervisor North Central District Health Department

Rinda Vanderhoof, RN Community Health Nursing Supervisor Laurel County Health Department

Sarah J.Wilding, RN, MPA, BSN Chief Nurse Department for Public Health
Kentucky Public Health Leadership Institute Mentors:

Beverly Siegrist, EdD, MS, RN Professor,

Western Kentucky University

Margaret Stevens, RN Nurse Consultant Department for Public Health

Special thanks to

Libby Sammons, Supervisor of the Local Health Administration Systems Section, Division of Administration and Financial Management,

Department for Public Health.2004 2005 Change Master Projects 2 Kentucky Public Health Leadership Institute Executive Summary: Supporting Practice Through Quality Nursing Documentation

Nursing documentation provides the basis for accountability and funding for public health nursing services.

Appropriate documentation includes a complete and accurate nursing note, assignment of the appropriate level of visit and identification of the appropriate primary and secondary diagnostic codes.

Observational site visits and interviews support that local health department nurses generally provide quality services.

However, nursing documentation is not always consistent with care provided or the level of visit that could be coded.

Caution to avoid fraudulent billing and failure to recognize the required components for appropriate documentation may lead to under-coding.

This may result in decreased revenue for local health departments, underreporting of services provided, and poor results from audits.

This Change Master Project goal is to increase operational competency of local health departments by: 1) assessing knowledge of current coding, 2) clarifying appropriate documentation and coding to support nursing practice, 3) developing and recommending tools to assist with training of local health department nurses, and 4) promoting the availability of ongoing training.
The methodology includes surveying local health department nurses regarding their comfort level with coding and documentation and perceived barriers.

Fifty one counties responded: over 35% reported never receiving training on coding and documentation and over 75% reported not having training within the year
examples of poor nursing documentation
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Over 80% of respondents felt annual training and tools to assist with coding levels and diagnostic codes would be helpful.

Interviews were conducted with state DPH staff to clarify requirements, identify barriers from a state and program perspective and explore strategies and resources.

Group members met to develop a format for tools, explore resources, assign tasks, and develop a timetable.

Research identified the Evaluation and Management Level 8b Tool as an effective computerized aid to nursing documentation and coding.

SOAP note format includes subjective, objective, assessment and plan information and provides documentation of the history, exam and decision-making that determine the appropriate service code.

The CPT coding system assigns a service code that denotes the complexity of the service and the reimbursement level.

The ICD-9 Code system is used to identify primary and secondary diagnoses.

T.R.A.I.N.is a web-based learning management system for public health that can be accessed in the worksite and other sites with Internet to be available for Local Health Departments include:

CD ROM - Evaluation and Management Level 8b

SOAP Note Guidelines to meet CPT Code Requirements

List of Most Commonly Used ICD-9 Diagnostic Codes

T.R.A.I.N.

Module for Nursing Documentation and Coding

2004 2005 Change Master Projects 3 Kentucky Public Health Leadership Institute Introduction and Background:

Nursing documentation provides the basis for accountability and funding for public health nursing services.

Appropriate documentation includes a complete and accurate nursing note, assignment of the appropriate level of visit and identification of the appropriate primary and secondary diagnostic codes.

Documentation must include 3 key components: history, exam and decision-making.

SOAP notes are a widely accepted format for appropriate nursing documentation and include subjective, objective, assessment and plan components.

The level of visit code reflected in the nursing documentation determines the appropriate reimbursement amount for public health nursing services.

The Kentucky Department for Public Health (KDPH) system uses Current Procedural Terminology (CPT) Codes to categorize the level of visit, which can range from a comprehensive evaluation for a new patient to a brief follow up visit for a return patient.

The International Classification of Diseases, 9th Edition (ICD-9) codes are used to categorize primary and secondary diagnoses.

The Evaluation and Management (E & M) Level 8b is reported by local and state health department nurses to be a useful tool for providing basic training and ongoing quality assurance on appropriate documentation and level of visit coding.

Problem Statement:

Observational site visits and interviews support that local health department nurses generally provide quality services.

However, nursing documentation is not always cons
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