Home Health Assessment Criteria: 75 Checklists for Skilled Nursing Documentation

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Home Health Assessment Criteria: 75 Checklists for Skilled Nursing Documentation

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Home Health Assessment Criteria: 75 Checklists for Skilled Nursing Documentation

Authors: Barbara Acello, MS, RN and Lynn Riddle Brown, RN, BSN, CRNI, COS-C

Initial assessments can be tricky—without proper documentation, home health providers could lose earned income or experience payment delays, and publicly reported quality outcomes affected by poor assessment documentation could negatively impact an agency’s reputation.

Ensure that no condition or symptom is overlooked and documentation is as accurate as possible with Home Health Assessment Criteria: 75 Checklists for Skilled Nursing Documentation. This indispensable resource provides the ultimate blueprint for accurately assessing patients’ symptoms and conditions to ensure regulatory compliance and proper payment. It will help agencies deliver more accurate assessments and thorough documentation, create better care plans and improve patient outcomes, prepare for surveys, and ensure accurate OASIS reporting.

All of the book’s 75-plus checklists are also available electronically with purchase, facilitating agency-wide use and letting home health clinicians and field staff easily access content no matter where they are.

This book will help homecare professionals:

  • Easily refer to checklists, organized by condition, to properly assess a new patient
  • Download and integrate checklists for use in any agency’s system
  • Obtain helpful guidance on assessment documentation as it relates to regulatory compliance
  • Appropriately collect data for coding and establish assessment skill proficiency


Table of Contents

Section 1: Assessment Documentation Guidelines

1.1. Medicare Conditions of Participation

1.2. Determination of Coverage Guidelines

1.3. Summary of Assessment Documentation Requirements

1.4. Assessment Documentation for Admission to Agency

1.5. Case Management and Assessment Documentation

1.6. Assessment Documentation for Discharge Due to Safety or Noncompliance

1.7. Start of Care Documentation Guidelines

1.8. Routine Visit Documentation Guidelines

1.9. Significant Change in Condition Documentation Guidelines

1.10. Transfer Documentation Guidelines

1.11. Resumption of Care Documentation Guidelines

1.12. Recertification Documentation Guidelines

1.13. Discharge Documentation Guidelines

Section 2: General Assessment Documentation

2.1. Vital Sign Assessment Documentation

2.2. Pain Assessment Documentation

2.3. Pain Etiology Assessment Documentation

2.4. Change in Condition Assessment Documentation

2.5. Sepsis Assessment Documentation

2.6. Palliative Care Assessment Documentation

2.7. Death of a Patient Assessment Documentation

2.8. Cancer Patient Assessment Documentation

Section 3: Neurological Assessment Documentation

3.1. Neurological Assessment Documentation

3.2. Alzheimer’s Disease/Dementia Assessment Documentation

3.3. Cerebrovascular Accident (CVA) Assessment Documentation

3.4. Paralysis Assessment Documentation

3.5. Seizure Assessment Documentation

3.6. Transient Ischemic Attack (TIA) Assessment Documentation

Section 4: Respiratory Assessment Documentation

4.1. Respiratory Assessment Documentation

4.2. Chronic Obstructive Pulmonary Disease (COPD) Assessment Documentation

4.3. Pneumonia/Respiratory Infection Assessment Documentation

Section 5: Cardiovascular Assessment Documentation

5.1. Cardiovascular Assessment Documentation

5.2. Angina Pectoris Assessment Documentation

5.3. Congestive Heart Failure (CHF) Assessment Documentation

5.4. Coronary Artery Bypass Graft Surgery (CABG) Assessment Documentation

5.5. Coronary Artery Disease (CAD) Assessment Documentation

5.6. Hypertension Assessment Documentation

5.7. Myocardial Infarction Assessment Documentation

5.8. Orthostatic Hypotension Assessment Documentation

5.9. Pacemaker and Defibrillator Assessment Documentation

Section 6: Gastrointestinal Assessment Documentation

6.1. Gastrointestinal Assessment Documentation

6.2. Cirrhosis Assessment Documentation

6.3. Crohn’s Disease Assessment Documentation

6.4. Hepatitis Assessment Documentation

6.5. Peritonitis, Suspected Assessment Documentation

6.6. Pseudomembranous Colitis Assessment Documentation

6.7. Ulcerative Colitis Assessment Documentation

Section 7: Genitourinary Assessment Documentation

7.1. Genitourinary Assessment Documentation

7.2. Acute Renal Failure Assessment Documentation

7.3. Chronic Renal Failure Assessment Documentation

7.4. Urinary Tract Infection (UTI) Assessment Documentation

Section 8: Integumentary Assessment Documentation

8.1. Integumentary Assessment Documentation

8.2. Skin Tear Assessment Documentation

8.3. Herpes Zoster Assessment Documentation

8.4. Leg Ulcer Assessment Documentation

8.5. Necrotizing Fasciitis (Streptococcus A) Assessment Documentation

8.6. Pressure Ulcer Assessment Documentation

Section 9: Musculoskeletal Assessment Documentation

9.1. Musculoskeletal Assessment Documentation

9.2. Arthritis Assessment Documentation

9.3. Compartment Syndrome Assessment Documentation

9.4. Fall Assessment Documentation

9.5. Fracture Assessment Documentation

Section 10: Endocrine Assessment Documentation

10.1. Endocrine Assessment Documentation

10.2. Diabetes Assessment Documentation

Section 11: Eyes, Ears, Nose, Throat Assessment Documentation

11.1. Eyes, Ears, Nose, Throat Assessment Documentation

11.2. Dysphagia Assessment Documentation

Section 12: Hematologic Assessment Documentation

12.1. Hematologic Assessment Documentation

12.2. Anticoagulant Drug Therapy Assessment Documentation

12.3. Deep Vein Thrombosis (DVT) Assessment Documentation

12.4. HIV Disease and AIDS Assessment Documentation

Section 13: Nutritional Assessment Documentation

13.1. Nutritional Assessment Documentation

13.2. Dehydration Assessment Documentation

13.3. Electrolyte Imbalances Assessment Documentation

13.4. Weight Loss, Cachexia, and Malnutrition Assessment Documentation

Section 14: Psychosocial Assessment Documentation

14.1. Psychosocial Assessment Documentation

14.2. Delirium Assessment Documentation

14.3. Psychotic Disorder Assessment Documentation

14.4. Restraint Assessment Documentation

Section 15: Infusion Assessment Documentation

15.1. Implanted Infusion Pump Assessment Documentation

15.2. Infusion Therapy Assessment Documentation

15.3. Vascular Access Device (VAD) Assessment Documentation
 

About the Authors

Barbara Acello, MS, RN, is an independent nurse consultant and educator. She has worked in long-term care for more than 30 years. In addition to owning and operating a school for nursing assistants, she helped write and develop mandatory state curricula for nurse aides and EMTs.

Lynn Riddle Brown, RN, BSN, CRNI, COS-C, of Roper St. Francis Home Care in Charleston, South Carolina, is a patient care coordinator and infusion nurse specialist. Previously, Brown practiced oncology nursing in Charlotte, North Carolina, for 10 years, holding positions as a floor nurse, inpatient hospice unit nurse, and charge nurse. During this time she held a certification in oncology nursing through the Oncology Nursing Society


Published: May 2015

Page count: 280
Dimensions: 8.5x11
ISBN: 978-1-55645-717-3