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Documentation & Data: Understanding how to effectively utilize both within case management and care coordination processes

Presented by 

LESA SCHLATMAN RN, BSN

CE STATEMENT

The Georgia Board of Nursing deems Southwest Georgia Area Health Education Center (SOWEGA-AHEC) as an approved provider for nursing continuing education (CE). This activity is approved for 1.0 contact hour towards the continuing education competency requirement for Georgia nursing licensure renewal. No partial credit offered. Activity #2021-03.

Note: Submission of registration information, attendance and completed evaluation/successful post-test required for Nursing continuing education certificates.

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DISCLOSURES & COMMERCIAL SUPPORT

Planners & presenter disclosed no potential conflicts of interest at this time

No commercial support provided for this educational activity

Funding Provided by Georgia Farmworker Health Program via Georgia State Office of Rural Health

OBJECTIVES

Recognize the importance of utilizing data, identifying trends, and 

tracking processes such as disease registries

Define why thorough documentation is important & what key 

information needs to be documented daily to meet compliance

Identify ways to improve documenting key care steps & tools that can 

be utilized (template/tool)

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Importance of Data Utilization

Identifying Trends & Tracking Processes

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HOW DO YOU CONVINCE A

LOAN OFFICER TO LOAN YOU

MONEY?DO YOU JUST WALK IN

AND SAY: “TRUST ME…I AM GOOD FOR IT”

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The level of riskThe level of benefit/ROIIs the treatment …….?

WITHOUT MEASURABLE DATATHERE IS NO WAY TO SAFELY DETERMINE RISKS & BENEFITS

Data: The Impact & Benefits

Why Use?• Provides tangible, measurable, and trackable information

Treatment:• Determine disease(s) prevalence within a community • Determine needed screenings based on prevalence• Determine treatment programs to implement• Identify necessary vs. unnecessary• Determine appropriate resources & services• What is working – what is not working

Cost:• Unnecessary treatment avoidance/Costly program reduction

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Data & Revenue?

A focus on revenue build is not recommended:• It can alter the focus on what is important• Patient centered can lose momentum• It is more about compliance• Improved revenue can be a side effect 

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Data & Trending

• Deviations from the norm• Reoccurring issues• Patient progress• Similar trends related to time/date• Disease process trends• Possible intervention needs

Single pieces of data allow a quick view of a specific moment in time for a patient. Multiple pieces of data spanning a large length of time allows a view of an 

entire treatment timeline. 

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January February March April

Blood Sugar Results

Normal Abnormal Abnormal Trend

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BP Tracking

BP Range 100/70 - 140/80 Abnormal Above 140/80 Treatment Change

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INR Tracking Example

https://www.inrpro.com/article.asp?id=27

“A disease registry is a tool for tracking the clinical care and outcomes of a defined patient population. Most disease registries are used to support care management for groups of patients with one or more chronic diseases, such as diabetes, CAD, or asthma.

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https://digital.ahrq.gov/key-topics/computerized-disease-registries

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Benefits of Disease Registries

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• Access to important/specific data in one central locations ‐ efficient

• Quantifies disease specific information and data points

• Individual patient progress vs. group progress

• Collective overview of all patients in a disease population

• Staff can easily determine patient compliance/non‐compliance

• With treatment and progress

• Completion/non‐completion of required testing

• Monitor provider compliance with required testing/treatment modalities

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Diabetes Tracking Registry

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18Creating a RegistryIdentify a priority disease populationOutline improvement goalsOutline important data points• Normal vs. abnormal• Meets vs. exceeds• Results• Testing/exam completionsAssign roles and duties• Data collection• Updates and monitoringBuild registry• Export from EMR to excel• Build within excel• Utilize EMR tool

http://journal.diabetes.org/clinicaldiabetes/v18n32000/pg107.htm

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Thorough DocumentationImportance & Meeting Compliance

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Definition: ThoroughDefinition: Thorough

• Executed without negligence or omissions• Extremely attentive to accuracy and detail• Complete, perfect

A thorough action or activity is one that is done very carefully and in a detailed way so that nothing is forgotten.

https://www.dictionary.com/browse/thorough?s=t

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High Quality DocumentationHigh Quality Documentation

http://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf

• Accurate, valid, and relevant• Authenticated (truthful, author is identified, nothing has been added or inserted)

• Dated and time‐stamped by author• Legible/readable• Uses standardized terminology• Reflective of the nursing process• Document all actions, complete• Document objective facts only• Accessible, retrievable permanently

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Quality IndicatorsQuality Indicators

Documentation Should Include:• Objective assessment (nursing info, data)• Subjective assessment (patient perspective)• Interpretation of findings (analysis)• Diagnosis• Plan of care (all patient needs to support self‐care)• Interventions with implementation info• Evaluations/modifications of care plans• Critical thinking that supports changes• Consultations/referrals (why, what, who, where, when)

https://www.crnm.mb.ca/uploads/ck/files/Documentation%20Guidelines%20for%20Nurses%20-%20web%20version.pdf

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Documentation of Care23

• During mobile visits it is important to include: patient name, date, 

time in and out, summary of care provided, patient responses, 

new orders, and future plans.

• It is always important to document what resources and education 

were provided to each patient, the patient responses, the level of 

understanding the patient met, and the amount of time spent 

doing each activity.

• What about if nothing changed or discussion was brief?

Brief Discussions24

True or False:

It is not necessary to document every outreach activity to every patient, 

especially if nothing has changed or the patient did not accept treatment

False: 

• Document everything – no matter how simple

• Outreach activities – support grant/funding parameters

• Supports proper billing

• Ability to quantify categories of work completed

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Include on annual cost reports and UDS tables• Clear depiction of who performs case management• % of time spent on CM vs. Medical activities• Case management – Table 5 line 24• Medical – Table 5 line 11

Example - Nurse works 40 hours (1 FTE): • 10hrs. Worked for CM, 30hrs. Worked for Medical• Line 24 = 0.25 FTE for case management• Line 11 = 0.75 FTE for medical• 0.25 FTE + 0.75 FTE = 1 FTE• A nurse does not just go under medical hours

Annual UDS Reporting

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Assisting patients in the management of their health and social needs• Assessment of patient NEEDS: medical and/or social service• Establishment of service plans• Maintenance of referrals• Tracking and follow-up or related systems

Case Managers• Who provide health education • Who provide eligibility assistance• Individuals identified as case management staff who perform above duties• Alternate staff trained as/called—case managers, care coordinators, referral

coordinators, or other local titles recognized as case management roles

Case Management Activities

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27Importance of UDS Reporting

FTE’s essential to show how funds are being spent across the three cost categories• No less than 50% of the program budget should be utilized for medical costs/personnel• Accuracy is crucial to show level of work being done & to meet compliance

• Utilized to monitor/evaluate health center performance  • Helps to establish or expand targeted programs related to reporting/trends• Identify services/interventions that improve access to care for vulnerable populations • Compared to national data: US population compared to ones who rely on the health care 

safety net for primary care

Summary: It supports the need for the programs utilizedIt supports that the work being done is appropriateIt determines site compliance with grant parametersIt identifies future needs

Importance: Legal Implications

Improper Documentation:

• Unable to prove that compliant 

and competent care was 

provided to each patient

• Unable to counter 

negligent claims

• Unable to prove 

policy/procedure followed

• Potential fraud scenarios

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Importance: Grant Needs

Allocation of funds:

• Documentation supports activities completed

• Compliant with outlined deliverables

• Were funds used appropriately?

Identification of activities:

• Determine types of care provided

• Mobile visit vs. clinic visit

• % of allocated job classes (case mgt.)

• Was care provided appropriate? Billable?

Charting Example

2/10/2020 10am: Met with Mrs. Smith to discuss diabetic medication, reviewed current med list, performed hands on demonstration of glucometer and showed competent skill, teach back shows competent knowledge of medication name/use/side effects. Blood sugar review shows consistent therapeutic levels. No further questions or needs at this time. Refills given and called to Walgreens. Nurse Miller

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Importance: Correct Revenue

• Improves identification of correct level of care

• Improves correct coding (If it applies)

• Ability to allocate correct charges

• Reduce missed charges

• Allocate funding correctly

Improving Documentation

Key Care Steps & Tools  

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Improving Your Documentation

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Develop a personal process to always follow• Head to toe assess• Questions asked – charting processUtilize “cheat sheets” to prompt accuracy• Available for each care setting• Includes all required informationUnderstand & follow facility processes• Standardized policy & proceduresAsk questions – seek feedbackProvide assist to others ‐ teamwork

Improve Facility Documentation

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Create templatesCreate “cheat sheets”• Available for each care settingStandardize your process• Individually• Facility wide – System wideUniversal process for all staff Communicate expectations ‐ accountabilityAudit work – real time follow upComplete daily tracking vs. monthly

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CM DocumentationCM Documentation

Ability to pull a report that indicates total of CM encounters• Label/coded encounters within EMR to easily identify (reach out to EMR)• Manual ongoing count (tracking log)• Daily tracking sheet (Not end of month)

• Hand to each staff• Require at end of day

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Expand Tracking LogExpand Tracking Log

• Include crucial tracking items• Update and review daily/weekly

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Real Time Documentation

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During point of care – not 1 to 3 hours later• Improves thoroughness of details• Avoid missed information• Prompts patient involvement• Efficient – removes extra steps or need to “re‐check”

Develop of process to follow• Repetition improves accuracy• Decreases errors and missed steps• Improves flow and efficiency

Outreach Documentation

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Tracking Logs:

• Manual: columns for all required items

• Prompts thorough documentation• Easily reviewed for compliance• Partner with EMR entry• Keep ongoing activity log for each patient

• EMR: entry/data points for all required items 

• Universal entry area known to all staff

• Standardized your process for all staff

Create compliance check list:

• Utilize on‐site to prompt thoroughness• Utilize to review if all required info included• Audit process with real time f/u and education

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OPEN DISCUSSION, SHARING, QUESTIONS

WHAT  NEW  PROCESSES  WILL  YOU   IMPLEMENT  BASED  ON  WHAT  WAS  

SHARED  TODAY?

Next StepsOverview of Upcoming Events

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Webinars:

• May 13th, 2021 (12pm – 1pm EST)

Workshop:

• April 22nd, 2021 (11am – 1pm EST)

1:1 Coaching Calls:

• Each clinic to set up call (1 or 2 depending on needs)

• Many have completed initial calls/2nd calls

• Still have a few clinics that need to schedule

• Reach out to Lesa Schlatman for scheduling:

• Lesa.schlatman@hometownhealthonline.com

REFERENCES & RESOURCES

Centers for Medicare & Medicaid Services:• http://www.cms.gov/

• https://www.dictionary.com/browse/thorough?s=t

• https://digital.ahrq.gov/key‐topics/computerized‐disease‐registries

• https://www.crnm.mb.ca/uploads/ck/files/Documentation%20Guidelines%20for%20Nurses%20-%20web%20version.pdf

• https://www.inrpro.com/article.asp?id=27

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Thank YouLesa Schlatman RN, BSN

Lesa.schlatman@hometownhealthonline com

https://www.hometownhealthonline.com/

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EVALUATION

Submission of registration information, attendance and completed evaluation/successful post-test required for CE certificates. Please select evaluation link from your email registration confirmation.

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