Home Health Assessment Criteria 75 Checklists for Skilled Nursing Documentation

Home Health Assessment Criteria: 75 Checklists for Skilled Nursing Documentation
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 Guidelines1.1. 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 GuidelinesSection 2: General Assessment Documentation2.1. 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 DocumentationSection 3: Neurological Assessment Documentation3.1. 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 DocumentationSection 4: Respiratory Assessment Documentation4.1. Respiratory Assessment Documentation
4.2. Chronic Obstructive Pulmonary Disease (COPD) Assessment Documentation
4.3. Pneumonia/Respiratory Infection Assessment DocumentationSection 5: Cardiovascular Assessment Documentation5.1. 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 DocumentationSection 6: Gastrointestinal Assessment Documentation6.1. 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 DocumentationSection 7: Genitourinary Assessment Documentation7.1. Genitourinary Assessment Documentation
7.2. Acute Renal Failure Assessment Documentation
7.3. Chronic Renal Failure Assessment Documentation
7.4. Urinary Tract Infection (UTI) Assessment DocumentationSection 8: Integumentary Assessment Documentation8.1. 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 DocumentationSection 9: Musculoskeletal Assessment Documentation9.1. Musculoskeletal Assessment Documentation
9.2. Arthritis Assessment Documentation
9.3. Compartment Syndrome Assessment Documentation
9.4. Fall Assessment Documentation
9.5. Fracture Assessment DocumentationSection 10: Endocrine Assessment Documentation10.1. Endocrine Assessment Documentation
10.2. Diabetes Assessment DocumentationSection 11: Eyes, Ears, Nose, Throat Assessment Documentation11.1. Eyes, Ears, Nose, Throat Assessment Documentation
11.2. Dysphagia Assessment DocumentationSection 12: Hematologic Assessment Documentation12.1. 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 DocumentationSection 13: Nutritional Assessment Documentation13.1. Nutritional Assessment Documentation
13.2. Dehydration Assessment Documentation
13.3. Electrolyte Imbalances Assessment Documentation
13.4. Weight Loss, Cachexia, and Malnutrition Assessment DocumentationSection 14: Psychosocial Assessment Documentation14.1. Psychosocial Assessment Documentation
14.2. Delirium Assessment Documentation
14.3. Psychotic Disorder Assessment Documentation
14.4. Restraint Assessment DocumentationSection 15: Infusion Assessment Documentation15.1. Implanted Infusion Pump Assessment Documentation
15.2. Infusion Therapy Assessment Documentation
15.3. Vascular Access Device (VAD) Assessment Documentation