Give nurses a checklist to help their admissions

Agency sees major paperwork improvements

The Visiting Nurse Association of Johnson County, based in Iowa City, IA, set a major goal in last year to become more efficient and accurate with documentation.

"We looked at what we had on the old forms and tried to combine these to do the essentials," says Joyce Eland, BSN, quality manager of the agency which serves a county in southeast Iowa with an average of 3,000 visits a month.

Due to OASIS, the field staff spent additional time with documentation, and this caused some frustration. The agency worked to streamline charts and documentation, including updating one of the most helpful tools, an admission checklist.

The checklist serves two major purposes, Eland says. First, it is a set of guidelines to remind nurses about the agency and Medicare’s admission criteria and how to check to make sure the patient meets those criteria. Secondly, it reminds nurses to present important information to patients, such as a patient-rights sheet. (See the VNA’s admission checklist, inserted in this issue.)

The admissions checklist has helped nurses improve documentation in many different areas, including how they ordered home care aide services, consistently writing down patient demographics, and having patients sign all necessary forms, Eland says.

Supervisors regularly do chart reviews to make sure the checklists are completed, and they’ll talk to nurses when they find items that have not been checked.

Checklist highlights

Here are some of the guidelines included in the checklist and how they have improved documentation and quality of care:

Consistent admission procedure. The agency first developed the admissions checklist six years ago in response to staff members having problems remembering everything they were supposed to do when first seeing a patient.

"We found that we kept writing out these instructions to guide people," Eland says, "and we thought, Why do we keep doing this every time? Why not keep it consistent with a checklist?’"

The first checklist mostly included a list of forms nurses were supposed to complete at the first visit, along with instructions on who would need a copy and what they should do after the visit.

Admission criteria. As Medicare’s concerns about fraud and abuse escalated in the late 1990s, the agency altered the checklist to include information about determining the appropriateness of admissions. This section now has nine steps a nurse must follow to determine if a patient is appropriate for admission, and this section is first on the checklist.

For example, the admission criteria include:

— Have physician and medical orders.

— Patient/family/private caregiver willing to provide care between visits.

— VNA care doesn’t duplicate other care: outpatient cardiac rehab or therapy-assisted living services.

"This was a way of reinforcing the criteria," Eland says. "We had some admissions of patients we thought weren’t really appropriate to admit, and it’s difficult to go back to a patient and say, We really don’t think we should have admitted you.’"

Make that call

The checklist’s admission criteria have made the staff more aware of government rules regarding home care service, and they have encouraged nurses to call in to the office to speak with a manager whenever they encounter a patient whose home care qualifications are questionable.

"I’m not saying we don’t have situations that come up, but we can catch it quicker than we used to, and we like that," Eland says.

Verbal order for care. About two years ago, the agency added a brief line, "Before Visit," where nurses must check whether there was a verbal order for care.

"We added that because there was a lot more concern about the verbal orders, and we found a few problems," Eland explains.

Although nurses were making the appropriate phone calls regarding care, they weren’t always documenting these calls. By adding this simple section to the checklist, it solved that problem.

Emergency plan. The agency added a check-off box for an emergency plan to the category, "If Appropriate for Admit, complete the following."

"We have a skeleton of an emergency plan, and it really relies on the staff writing in some information that’s individualized for patients to make it a good plan; that was a reminder to them to do that," Eland says.

OASIS. The checklist reminds nurses to turn in their OASIS assessment within two days after the last visit, and it forces them to examine whether various OASIS information is accurate, including the payer source, diagnosis order, and qualifying service for Medicare.

Demographics. The staff had not been consistently completing the patient identification sheet. For example, they didn’t always write out the directions to the patient’s home or give the names of the pharmacy or agencies involved in the case.

"And that’s our place of communication for those things," Eland says. The agency added a reminder about demographics to the checklist. It reads, in part: "Emergency contact? Other Agen-cies? Pharmacy? Directions?"

Since this was added last year, the staff have improved their documentation of patient demographics, Eland adds.

Home care aide/homemaker services. This is another area that was added in 1999 because of performance improvement concerns.

"We were discovering on some of our audits that nurses forget they are responsible for home care aide orders," Eland says. "They were changing the frequency of home care aide visits or putting a home care aide on a case, and we had an omission of orders for home care aide services."

In other words, nurses didn’t get the doctor’s order on the initial plan. The checklist now reminds them to do so with the terse instructions: "HCA/HM services: Call office to schedule; write care plan (orig - office; copy - patient). Write order HCA!!"

The problem has improved since the reminder was added to the checklist, Eland says. "On the initial plan, we’re doing well, and we’ve made progress on it if there are any changes in service; but we still have a few isolated incidents and are working on some other ways to correct those."

Psychiatric consent. Another new addition to the checklist is under the Supervisory Review section. The last category notes several areas that should receive special attention, and one is "Specific Consent Mental, HIV, Substance."

"One thing we noticed last year is that we have a fair number of patients with psychiatric concerns, and there were frequent requests for information," Eland says. "When we went back to the consent form, we didn’t always see that they had a mental health-specific consent form signed or initialed, so that’s an area we did an inservice on."