Enhancements have been made to the Skilled Nursing Visit Assessment with Clinical Point of Care Software version 2465 dated 7/11/16.
Additional documentation fields have been added in the Supportive section for clinicians to detail the patient’s continued need for skilled service based upon the patient’s overall medical condition and complexity. The Narrative field in the narrative section has been updated with a reminder to include documentation of the patient response or changes in behavior related to teaching, therapies or services provided. The next and Future visits field in the Narrative section of the clinical note has been updated to include documentation of the plan for the next visit. A documented Next and Future Visit with Plan will now display on the next skilled nursing visit added in the default screen that displays immediately after the billing information screen. The Clinician next visiting the patient will now have the plan for their visit readily available for review as they begin their visit with the patient.
A warning box will now appear if the clinician tries to exit the Skilled Nursing Visit Assessment and have left certain key documentation fields blank. The Warning will indicate to the clinician that their documentation appears to be incomplete. The Warning will detail the sections missing documentation.
The updates to, addition of documentation fields and warning for incomplete documentation have been added to align with the Medicare Benefit Policy Manual details of requirements for home health clinical notes found under 40.1.1 General Principles Governing Reasonable and Necessary Skilled Nursing Care, the Conditions of Participation and Best Practices. Allegheny Software realizes agencies are faced with increasing numbers of requests for medical record review, probe and educates and pre-claim review by payer sources. The documentation field and warning enhancements are meant to assist agencies in ensuring all necessary and required documentation is present to meet eligibility and documentation requirements.