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Q&A: Documenting patients’ post-acute choices

Case Management Weekly, March 10, 2010

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Q: Is documenting post-acute care choices given to patients sufficient or is a signature (patient’s or significant other’s) necessary in the medical record?

A: Hospital staff must give patients a choice of  available and appropriate post-acute services and must document that choice. Documenting the final choice—including the name of the facility and the level/type of service at the facility to which the patient was referred—is important for coding and billing purposes.

A hospital’s policy and procedure determines how to document that choice. Medicare doesn’t tell hospitals how to document choice—although some wish that it would—because of the varied nature of hospitals. Medicare wisely allows hospitals to develop policies based on what will best meet the needs of their patient population.

Options for documenting patients’ post-acute choices include:

• A form that a patient/significant other must sign
• A staff-written narrative note in the medical record. 
• Discharge technology such as the eDischarge software-as-a-service from Curaspan Health Group, which automatically generates a choice letter given to patients and their families. The letter is a function of the software that allows its inclusion in patients’ medical records.

The Conditions of Participation for Discharge Planning and the Interpretive Guidelines for Hospitals (p.293) includes references to the rules..

Consider the following recommendations to improve documentation of post-acute choice:

• Review your own hospital policy. Many case managers are unaware of their facilities’ choice policy. 
• Audit your current practice by asking staff members who perform discharge planning how they satisfy the choice requirement. 
• Automate the discharge planning process to ensure valid evidence that: 
  • Appropriate and available HHAs, SNFs and hospices are on the list
  • The patient received a list from which to choose
  • The final choice and level of care was documented and is a permanent part of the medical record.

Jackie Birmingham, RN, MS, vice president of Curaspan Health Group answered this week’s question.

Do you have a question about a case management topic? Send it to editor Ben Amirault at bamirault@hcpro.com. An answer to your question might appear in a future issue of Case Management Weekly.

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