Now, when you look deeper into documentation it becomes more complicated than just documenting different kinds of behavior. Most facilities such as mine have several residents that are supported by Medicaid. In order for the facility to be paid my Medicaid they must comply with Medicaid documentation standards. There are so many complications with this. At times the standards change and it is not accurately communicated to the MHCs and therapists doing the documentation. Sometimes the standards have always been there but for some reason the facility either did not know/understand the standards or they just did not comply with them. Noncompliance leads back to paybacks to Medicaid from the facility because Medicaid will not pay if documentation is non-compliant. There are specific things that Medicaid is looking for.
For instance, only certain abbreviations can be used in documentation: "Q" for "every", "@" for "at", and "&" for "and". You cannot use "min" for "minutes" or "cont" for "continued," which are both common abbreviations that my facility used on a daily basis, until we discovered we were not getting paid by Medicaid for those residents whose documentation was not correct. Furthermore, there are common errors made in documentation that are difficult to distinguish the difference at times. When continuing a narrative note on the back of the page, you must continue it in a very specific way.
(continued) MY NAME, MHC MY NAME, MHC (continued)
When correcting errors you must put one line crossed through the error and initial it.
There are even specific times to which staff should begin writing documentation narratives. If one writes a narrative and it is before the acceptable time to write narratives, it is unacceptable. Furthermore, if you write one documentation narrative and something happens after you wrote it, you must write another narrative documenting that new event.
When documenting groups therapy sessions, it is unacceptable to simply mention that the resident "actively participated," which is another common mistake that my facility made. You must give examples as to how the resident participated and acted in group. This way there is support to back up any evaluations you made on the resident. If you think they participated sufficiently, describe what they did. If a resident refuses to participate in group, document what they were doing instead and where they were. If you simply say, "resident refused" or "did not participate" there are not enough details to determine if this group intervention can count toward the required number of groups per week as required by Medicaid. Furthermore, a certain amount of residents need to be in group in order for it to count as a group intervention. If one documents group as having "one participant" it will not count as a valid group. Because it is required to document the location of every resident every fifteen minutes, group notes and monitoring should match. It would not be acceptable if a group note documented group taking place from 1800-1830, but the monitoring says that Robert was in his room at 1800, in the hall at 1815, and with his therapist at 1830.
There are many miscommunications as to what exactly is correct documentation. There is a very large problem with what Medicaid considers "child specific" narratives. It appears that there is no clear explanation as to how detailed a narrative has to be. Should staff document how many times a resident turns in their sleep? Should staff document how often residents speak to one another? We keep tally marks as to how many times they curse, but should we document exactly which curse words they are using? At times, although it sounds ridiculous, it appears that Medicaid requires staff to document how much time they spend in the restroom.
I mentioned a few things in this entry that I plan on elaborating more on later. This includes groups and special precautions. I will explore these topics next.