HOME HEALTH ASSESSMENT CRITERIA HOME HEALTH

1 75 Checklists for Skilled Nur sin g DocumentationHOME HEALTHASSESSMENTCRITERIAB arbara Acello, MS, RNLynn Riddle Brown, RN, BSN, CRNI, COS100 Winners Circle, Suite 300 Brentwood, TN HHAC75a divisionof BLRHOME HEALTH ASSESSMENT CRITERIA75 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 could lose earned income or experience payment delays, and publicly reported quality outcomes affected by poor ASSESSMENT documentation could negatively impact an agency s reputation. Ensure that no condition or symptom is overlooked and documentation is as accurate as possible with home HEALTH ASSESSMENT CRITERIA : 75 Checklists for Skilled Nursing Documentation.

2 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 care plans and improve patient outcomes, prepare for surveys, and ensure accurate OASIS of the book s 75-plus checklists are also available electronically with purchase, facilitating agencywide use and letting home HEALTH clinicians and field staff easily access content no matter where they 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 proficiencyHOME HEALTH ASSESSMENT CRITERIA ACELLO BROWN-C29134 home HEALTH Assesment_Book_Cover Front and 15/21/15 12:57 PMHome HEALTH ASSESSMENT CRITERIA : 75 Checklists for Skilled Nursing Documentation is published by HCPro, a division of BLR.

3 Copyright 2015 HCPro, a division of BLRAll rights reserved. Printed in the United States of America. 5 4 3 2 1 ISBN: 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 the Copyright 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 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.

4 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 Circle Suite 300 Brentwood, TN 37027 Telephone: 800-650-6787 or 781-639-1872 Fax: 800-785-9212 Email: HCPro online at and the Authors ..ixPurpose ..xSection 1: ASSESSMENT Documentation Medicare Conditions of Participation .. Determination of Coverage Guidelines .. Summary of ASSESSMENT Documentation Requirements .. ASSESSMENT Documentation for Admission to Agency .. Case Management and ASSESSMENT Documentation.

5 ASSESSMENT Documentation for Discharge Due to Safety or Noncompliance .. Start of Care Documentation Guidelines .. Routine Visit Documentation Guidelines .. Significant Change in Condition Documentation Guidelines .. Transfer Documentation Guidelines .. Resumption of Care Documentation Guidelines .. Recertification Documentation Guidelines .. Discharge Documentation Guidelines ..48 Contentsiii 2015 HCPro home HEALTH ASSESSMENT CRITERIA : 75 Checklists for Skilled Nursing DocumentationSection 2: General ASSESSMENT Vital Sign ASSESSMENT Documentation .. Pain ASSESSMENT Documentation .. Pain Etiology ASSESSMENT Documentation .. Change in Condition ASSESSMENT Documentation.

6 Sepsis ASSESSMENT Documentation .. Palliative Care ASSESSMENT Documentation .. Death of a Patient ASSESSMENT Documentation .. Cancer Patient ASSESSMENT Documentation ..71 Section 3: Neurological ASSESSMENT Neurological ASSESSMENT Documentation .. Alzheimer s Disease/Dementia ASSESSMENT Documentation .. Cerebrovascular Accident (CVA) ASSESSMENT Documentation .. Paralysis ASSESSMENT Documentation .. Seizure ASSESSMENT Documentation .. Transient Ischemic Attack (TIA) ASSESSMENT Documentation ..98 Section 4: Respiratory ASSESSMENT Respiratory ASSESSMENT Documentation .. Chronic Obstructive Pulmonary Disease (COPD) ASSESSMENT Documentation .. Pneumonia/Respiratory Infection ASSESSMENT Documentation.

7 107 ContentsivHome HEALTH ASSESSMENT CRITERIA : 75 Checklists for Skilled Nursing Documentation 2015 HCProContentsContentsSection 5: Cardiovascular ASSESSMENT Cardiovascular ASSESSMENT Documentation .. Angina Pectoris ASSESSMENT Documentation .. Congested Heart Failure (CHF) ASSESSMENT Documentation .. Coronary Artery Bypass Graft Surgery (CABG) ASSESSMENT Documentation .. Coronary Artery Disease (CAD) ASSESSMENT Documentation .. Hypertension ASSESSMENT Documentation .. Myocardial Infarction ASSESSMENT Documentation .. Orthostatic Hypotension ASSESSMENT Documentation .. Pacemaker and Defibrillator ASSESSMENT Documentation ..133 Section 6: Gastrointestinal ASSESSMENT Gastrointestinal ASSESSMENT Documentation.

8 Cirrhosis ASSESSMENT Documentation .. Crohn s Disease ASSESSMENT Documentation .. Hepatitis ASSESSMENT Documentation ..14 Peritonitis, Suspected ASSESSMENT Documentation .. Pseudomembranous Colitis ASSESSMENT Documentation ..15 Ulcerative Colitis ASSESSMENT Documentation ..151 Contentsv 2015 HCPro home HEALTH ASSESSMENT CRITERIA : 75 Checklists for Skilled Nursing DocumentationSection 7: Genitourinary ASSESSMENT Genitourinary ASSESSMENT Documentation .. Acute Renal Failure ASSESSMENT Documentation ..15 Chronic Renal Failure ASSESSMENT Documentation ..15 Urinary Tract Infection (UIT) ASSESSMENT 8: Integumentary ASSESSMENT Integumentary ASSESSMENT Documentation.

9 Skin Tear ASSESSMENT Documentation .. Herpes Zoster ASSESSMENT Documentation .. Leg Ulcer ASSESSMENT Documentation .. Necrotizing Fasciitis (Streptococcous A) ASSESSMENT Documentation .. Pressure Ulcer ASSESSMENT Documentation ..179 Section 9: Musculoskeletal ASSESSMENT Musculoskeletal ASSESSMENT Documentation .. Arthritis ASSESSMENT Documentation .. Compartment Syndrome ASSESSMENT Documentation .. Fall ASSESSMENT Documentation .. Fracture ASSESSMENT Documentation ..198 ContentsviHome HEALTH ASSESSMENT CRITERIA : 75 Checklists for Skilled Nursing Documentation 2015 HCProContentsContentsSection 10: Endocrine ASSESSMENT Endocrine ASSESSMENT Documentation .. Diabetes ASSESSMENT Documentation.

10 207 Section 11: Eyes, Ears, Nose, Throat ASSESSMENT Eyes, Ears, Nose, Throat ASSESSMENT Documentation .. Dysphagia ASSESSMENT Documentation ..212 Section 12: Hematologic ASSESSMENT Hematologic ASSESSMENT Documentation .. Anticoagulant Drug Therapy ASSESSMENT Documentation .. Deep Vein Thrombosis (DVT) ASSESSMENT Documentation .. HIV Disease and AIDS ASSESSMENT Documentation ..222 Section 13: Nutritional ASSESSMENT Nutritional ASSESSMENT Documentation .. Dehydration ASSESSMENT Documentation .. Electrolyte Imbalances ASSESSMENT Weight Loss, Cachexia, and Malnutrition ASSESSMENT Documentation ..243 Contentsvii 2015 HCPro home HEALTH ASSESSMENT CRITERIA : 75 Checklists for Skilled Nursing DocumentationSection 14: Psychosocial ASSESSMENT Psychosocial ASSESSMENT Documentation.