While documentation and care planning requirements are a well-established part of the daily SNF routine, it is important to consider the impact of Coronavirus (COVID-19) on each resident’s treatment plan. Along with managing and supporting those known or suspected to be infected, additional challenges arise in the form of psychosocial well-being for individuals in the SNF setting – whether the virus is in your facility or not.
For individuals with known or suspected Coronavirus infection, documentation and care planning should focus on signs and symptoms of infection, thorough respiratory assessment, management of symptoms, and adherence to (and potential psychosocial effects of) transmission-based precautions. Also, strict visitation restrictions, disbandment of group activities, and cessation of communal dining leave SNF residents essentially sequestered to their rooms. This necessary social distancing is difficult for any individual and can be exceedingly challenging for those residents already dealing with past trauma, dementia, and/or mood disorders and mental illness. Consider these areas when developing care plans surrounding COVID-19:
- Actual/potential infection
- Transmission-based precautions
- Risk for social isolation
- Risk for alteration in mood state
- Risk for recurrence of trauma-related anxiety or depression
Under the 1135 Medicare Waiver, residents may qualify for skilled services without a 3 day hospital stay or 60 day period of wellness in some circumstances. Documentation should clearly describe medical necessity and justify the decision to apply the waiver and initiate skilled care.
As always, each individual is unique and may exhibit a different clinical presentation or wide range of symptoms. Documentation and care planning must reflect each individual’s current status, personalized interventions, and unique circumstances regarding care and services.
Check out Proactive’s skilled charting guidelines toolkit which now includes a complimentary guide to COVID-19 Charting and Care Planning.
Blog by Eleisha Wilkes, RN, RAC-CT, RAC-CTA, Proactive Medical Review
Click here to learn more about Eleisha and the rest of the Proactive team.