According to the Patient-Driven Payment Model (PDPM), skilled nursing facilities (SNFs) are required to have documentation in the medical record that will allow a medical reviewer, in the case of an additional documentation request (ADR), to determine that Medicare Part A skilled services were provided and that those services were reasonable and necessary. This requirement goes hand in hand with the fact that SNFs are also required to have documentation in the medical record that will allow them to determine whether or not a patient was eligible for those services. Under PDPM, providers receive payment for all five case-mix-adjusted payment components for every resident regardless of whether or not the resident requires skilled nursing or skilled therapy services. These components include physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and non-therapy ancillaries (NTA). As a direct result of this, nursing documentation has become an increasingly important component in sustaining PDPM reimbursement. Although having the proper documentation is not a requirement for the definition of a “skilled” service in and of itself, it is the way by which providers demonstrate that each Medicare patient requires and receives skilled care. The documentation in the medical record is meant to show the requirement for the skilled services provided and should contain the following details:
- A thorough nursing evaluation
- Current functional status
- Responsiveness to treatments
- Progress toward goals
- The need for continued care in the facility
Example of a Daily Progress Note
Resident admitted 12/5/22 with a dx of exacerbation of COPD. The patient’s highest temperature during the past 24 hours was 99.5 degrees; her blood pressure is 148/77 and her pulse is between 87 and 106. Current SpO2 is 93% on 3L O2 via nasal cannula. Resident denies loss of appetite, chills, fever, or fatigue. Weight 165lbs, BMI 31.3. The elderly female is alert, no acute distress, cooperative, fairly obese and is in a wheelchair. Requires maximum assist x1 with toileting, transfers, and bed mobility. Resident requires set-up assistance with eating. Pleasant and cooperative with care. Resident has a home goal and expresses excitement regarding the approaching holidays and is looking forward to celebrating with her family who visits often. The resident continues to require daily skilled nursing as her treatment is ongoing and her current condition has not yet stabilized. Currently, SpO2 drops to 83-85% with minimal activity. Resident receiving PT/OT 5x per week to assist with daily tasks needed to improve resident’s independence; see therapy progress notes. Resident requires the daily skills, knowledge, and judgement of a nurse to ensure medical safety and promote recovery.
HEART: Rate and rhythm are regular, without murmur, gallop, or rub. Denies chest pain, or orthopnea.
LUNGS: Totally free of expiratory wheeze. There are rhonchi present on her right midbase. This morning she had a productive cough and is now coughing up green, purulent sputum. Physician made aware and currently waiting return call. Albuterol nebulizer treatment given as ordered, with effectiveness. After treatment, SpO2 improved to 97% on 3L O2 via NC with relief of “chest tightness” voiced per resident.
GASTROINTESTINAL: Soft and nontender. Her x4 bowel sounds are normal. Denies vomiting or nausea.
NEURO: Alert and orientated x3 with clear speech. Pupils are equal and reactive. Tongue is midline. Denies tingling, numbness or focal weaknesses.
MUSCULOSKELETAL: Her spine is non-tender from the neck to the lumbar region. She has an excellent range of motion in her shoulders, elbows, wrists, and fingers. Her bilateral grip strength is equal. Full ROM to both upper and lower extremities. 2+ pitting edema to bilateral ankles and feet. Compression stocking present.
GENITOURINARY: Denies changes in urine color. Denies dysuria.
SKIN: No petechiae, bruising or rashes.
This example demonstrates that skilled observation and monitoring are necessary for potential complications related to the resident’s diagnosis. Observation and monitoring by skilled nursing personnel of the patient’s oxygen levels and vitals are required to prevent further decline and ensure adequate oxygenation. The medical documentation must describe the skilled services that require the involvement of nursing personnel to promote the patient’s recovery and medical safety in view of the patient’s overall condition.
Example of a Shift Note
Resident skilled for management of COPD exacerbation. Her SpO2 was 88% on 3L O2 via NC. Within 15 minutes of administration of Albuterol nebulizer SpO2 improved to 97% on 3L O2 via NC. Resident has an occasional non-productive cough. Lung sounds are clear throughout this afternoon; denies pain. Resident ate very little for lunch and has had decreased intake over the last 2 days. When questioned about decreased intake, she relays that she has had nausea that began at breakfast yesterday. Encouraged to increase fluid intake to prevent dehydration. Referral was made to RD due to decreased intake. Zofran was administered due to nausea.
In this example, skilled observation is needed to observe & assess: vital signs, respiratory status, pain, GI status, nutritional status, hydration status and ADL status.
A particular diagnosis or charting that the resident is “skilled” does not stand alone to meet the definition of a skilled service. The resident’s clinical condition and response to therapy, as well as the specific skilled requirement and medical necessity for services, must all be clearly demonstrated in the documentation. An additional narrative note may be required if using a standard form for skilled documentation (such as a check-off form) to reflect patient-centered skilled services. This is because the need for and administration of the skilled nursing condition or service may go beyond this basic template. Section 30 in Chapter 8 of the Medicare Benefit Policy Manual outlines factors for consideration in determining SNF level of care, defines skilled services, and further lists principles for determining whether a service is skilled.
Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 8. https://www.cms.gov/Regulations-and Guidance/Guidance/Manuals/Downloads/bp102c08pdf.pdf