Agencies are struggling to maintain medical necessity when clinicians submit contradictory documentation in patient notes and should evaluate when and how different disciplines communicate about patient care.
Nurses and therapists can struggle to collaborate when they work separately and sometimes focus on different outcomes. But providers that fail to coordinate and document interdisciplinary communication could face claim denials, survey citations or legal action.
“Any time we have more than one discipline caring for a patient, there needs to be an opportunity for the interdisciplinary team to get together and share notes and observations,” says Sharon Harder, president of C3 Advisors in Wheaton, Ill. She notes that the Conditions of Participation require agencies to maintain communication between all practitioners involved in a patient’s plan of care.
Interdisciplinary coordination is about more than checking off boxes on an electronic medical record (EMR), Harder says. Issues commonly occur when one discipline prepares to discharge a patient but does not converse with other parties about the decision.
For example, consider a patient whose homebound status rests on his inability to ambulate independently. If physical therapy discharges the patient early and states in the evaluation that the patient can now walk on his own, other practitioners may be unable to continue care.
“If the patient does not have some kind of medical contraindication that we can insert to defend our homebound status, then nursing is hanging out there with a patient that’s not technically homebound and they can’t serve,” Harder says.
Complications can also arise from small contradictions in a patient’s EMR, says Jill Dyer, owner of JID Consulting and Coding in Golden, Colo.
For instance, a nurse may visit a patient in the morning and record normal blood pressure, but a therapist notes an elevated blood pressure several hours later. Dyer says that this could be a simple mistake, but an administrator must follow up with both clinicians to address the inconsistency.
If the issue is unresolved or leads to complications in patient outcomes, the agency may face legal action, she notes.
“If it’s a one-day thing, as long as there was no consequence, it’s probably not that big of a deal,” Dyer says. “But when there’s a consequence following it — the patient went to the hospital or fell — now you’ve got an issue.”
Utilize QA to catch mistakes
Care coordination between disciplines is one of the most common deficiencies uncovered in surveys, says Ashlee Oliver, owner of JWO Home Health Consultants in Crown Point, Ind.
Agencies can mitigate survey risks by ensuring that employees reviewing documentation are prepared to identify and manage discrepancies, Oliver says.
“Anyone involved in quality assurance and documentation review should be well versed in agency, Medicare and accrediting bodies’ requirements for care coordination and communication amongst the interdisciplinary team,” she notes.
Discharge is an important time for pinpointing inconsistencies, Dyer says. She notes that this is especially true for providers that employ separate Quality Assurance (QA) staff members for nurses’ and therapists’ notes. “Whoever’s doing a QA of that discharge assessment and discharge OASIS should be glancing at both nursing and therapy and making sure that they don’t have conflicting information.”
If the QA team does come across inconsistencies in a patient’s EMR, Oliver notes that they should immediately notify a supervisor and any clinicians and physicians included in the plan of care.
Educate, follow up with practitioners
Experts say that all parties involved in the patient’s plan of care should maintain consistent contact from the initial assessment until discharge. The following tips can help grow coordination between disciplines throughout care:
Encourage review before submission. Though it’s a best practice, experts note that it’s unrealistic to expect employees to have the time to read through every discipline’s notes on shared patients. Instead, Oliver suggests that agencies encourage their practitioners to view visit notes that fall within the week of the visit they are actively documenting.
Though it’s less ideal than real-time communication, Oliver adds that this can help bridge gaps in patient care when clinicians are behind on their documentation. “If there was a failure of communication, they should be able to identify any changes in the patient’s condition or treatment plan by viewing the notes.”
Build trust between disciplines. Nurses and therapists who are full-time or routinely on-call for a specific agency will often work on the same patients, Dyer says. “You’re going to know each other, and just having that good working relationship helps you know that the nurse or therapist is going to call if there’s an issue.”
Prioritize case conferences. Case conferences are essential in maintaining interdisciplinary coordination, Dyer says. She notes that agencies must ensure that nurses and therapists are on the same page before entering a new billing period and deciding to discharge or recertify a patient.
“It’s important to have the disciplines represented when you’re talking about patients and look for input from each of those disciplines,” she says. “If there’s an issue, then the nurse or the therapist for that patient could bring it up in that case conference.”
Record communication. Documenting interdisciplinary correspondence is as simple as leaving a communication note in the EMR, Harder says. She adds that the note’s contents should include patient updates, how certain steps or changes will impact other disciplines and when the practitioners connected to discuss the patient’s needs.
Reach out to clinicians who do not document communication, Oliver suggests. “Return the note asking if the clinician completed the required care coordination and to document as such.”
Ask the clinicians to update their documentation to reflect the correct information about the patient’s condition once the miscommunication is resolved, she adds.
Encourage ongoing education. “Provide one-on-one training to the field clinician responsible for the incorrect assessment or information,” Oliver says. She notes that some mistakes may stem from a clinician misunderstanding or overlooking part of the visit documentation.
Simple notes prevent miscommunications
Here is an example of a note that a clinician might leave in an EMR to document interdisciplinary communication after a patient’s caregiver found that the patient had new bruises and cuts but did not report a fall:
(Writer) informed the patient’s home health physical therapist, DON and patient’s MD regarding the new bruise and skin tear to patient’s left arm via phone calls on 07/12/2024. PT and DON verbalized understanding. VO obtained from MD for new wound care to left arm: cleanse area with normal saline, allow to air dry, cover with dry gauze and secure with tape daily until healed and as needed in the event the bandage becomes loose or soiled. SN may teach the patient’s caregiver how to perform wound care in SN’s absence. See associated order in EMR.
Example provided by Ashlee Oliver, owner of JWO Home Health Consultants in Crown Point, Ind.