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Try Using These Quantifiable Measures To Nail Your Terminal Diagnosis Documentation

Published on Fri Jan 14, 2011

Without objective evidence of your patient's decline, you are risking claims denials and your compliance record. HHH MAC CGS offers these examples of quantifiable measures it likes to see in hospice patients' records:

  • Change in patient's weight (pounds or kilograms)
  • Worsening diagnosis lab results (increase, decrease)
  • Change in pain:

- Type (ache, throb, sharp)

- Intensity (level 0-10)

- Location (upper, lower)

- Frequency (hourly, daily)

- Medication usage (dosage, frequency)

  • Change in responsiveness (fading, alert, unresponsive)
  • Skin thickness/condition (fragile, intact, tears easily)
  • Dependence on ADLs

- Occurrences of incontinence

- Dress (assisted, unassisted)

- Bathe (assisted, unassisted)

- Ambulation ability (assisted, unassisted)

- Ambulation distance (feet, steps)

  • Change in anthropomorphic measures

- Upper arm measurement (inches, centimeters)

- Abdominal girth (inches, centimeters)

  • Change in signs

- Respiratory rate (increased, decreased)

- Oxygen flow rate (liters)

- Hyper/hypotension

- Radial/apical pulse (tachycardic, bradycardiac, regular, irregular)

- Edema (level 1-4, pitting, non-pitting)

- Turgor (slow, normal)

  • Changes in strength, weakness (level 0-5)
  • Change in lucidity (oriented, confused)
  • Measurement/change in intake/output

- Amount (cups, liters, ounces, teaspoons, mgs, ml, cc)

- Frequency.

Plus: General quantifiable values to keep in mind are size, timeframe, and frequency, CGS suggests. Other values may include head elevation and speech pattern.

Note: See the entire documentation tool, which also addresses admission requirements, physician services, and more, at www.cgsmedicare.com/hhh/education/materials/pdf/Hospice%20Documentation%20Tool_H-021-01_07-2011.pdf.

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