By Dr. Saul Ebema
The single-most-scrutinized area for hospice providers by the U.S centers for Medicare & Medicaid Services (CMS) is patient eligibility. While most hospice programs are admitting eligible patients, they often don’t prove eligibility with their documentation. From admission, to clinician visits, to recertification, nurses, social workers, and chaplains must document unequivocally whether the patient is chronically ill versus terminally ill.
The physician’s narrative and face-to-face visits must also clearly demonstrate a less-than-six-months prognosis.
Eligibility documentation is the primary area requiring significant improvement in most hospice programs. It is also the most at-risk area for payment by CMS.
This article will focus on helping clinical hospice staff- especially chaplains to understand their role and learn ways to improve this process. Your documentation is vital for the survival of your hospice.
For proper hospice documentation, there are other formats but I prefer the DAROP format. This format stands for five sections that comprise this narrative framework:
Listed below are each of the five sections that comprise the DAROP format, with the instructions I provide to Chaplains and illustrative examples based on a 58-year-old male patient with a hospice diagnosis of congestive heart failure.
Write what you observed at the beginning of your visit and relate it to the hospice diagnosis. Write your assessment of need in this session and the care plan you are addressing.
In collecting Data, these are steps to follow;
- Patient identification- Very important if the patient is in a skilled nursing facility to avoid visiting the wrong patient.
- Who helped you to identify the patient? Was it the family, facility staff, caregiver or facial recognition from your previous visit, or patient’s name or room number? (this is important because it is easy to make a mistake and visit the wrong patient)
- Know the patient’s diagnosis and the symptoms of the diagnosis- The patient in our case study has a diagnosis of congestive heart failure. Some of the symptoms of CHF are; shortness of breath, swelling, rapid weight gain, Confusion or memory loss, coughing, feeling tired and fatigued.
Sentences in this section should start with “patient” or “family” as you are documenting what you saw at the beginning of the session.
For example, “Patient was received sitting up in the living room watching television with his wife. He appeared melancholic as evidenced by his flat affect and downcast eyes. He denied pain and stated, “I’m just kind of tired today.”
If patient was in a skilled nursing facility you could say; “Patient was identified by facility staff or patient was identified through facial recognition from previous visit. Chaplain met pt sitting up by the common area watching tv..etc
Care plans being addressed by visit: altered mood (depression) and anticipatory grief.
Write what you did in the session to address the needs you assessed.
Sentences in this section should start with your position (e.g., chaplain) as you are documenting your interventions for the patient and/or family.
For example, “Chaplain assessed patient’s mood as depressed and provided supportive counseling, empathetic listening, and validation. Chaplain introduced the concept of a legacy project and offered to work with patient and family on documenting the patient’s life story. Encouraged life review and reminiscence. Contacted RN case manager, Julie Burns, and reported observations of patient’s depression.”
Write observable outcomes of your actions or interventions.
Sentences in this section should start with “patient” or “family” as you are documenting what you observed as the result of your interventions.
For example, “while the patient was relatively guarded when asked about his depression and current situation, his affect significantly brightened during life review. His wife shared stories of their courtship 30 years ago, and he joined in the discussion with additional stories. While reminiscing, they held hands and laughed. Overall, the patient continues to struggle with his depressed mood, and when the wife walked the chaplain outside at the end of the visit, she shared her concerns for her husband. There were no signs of suicidal ideation. She agreed to a legacy project with him as a coping skill to lift his mood.”
Write all observations of physical decline related to the diagnosis. You are answering the question: “Within your scope of practice, what do you see that makes this patient hospice-eligible today?”
Sentences in this section should start with “patient” as you are describing your objective and subjective observations of his hospice eligibility.
For example, “Patient was utilizing oxygen throughout the visit today whereas on previous visits, he would take it on and off. His feet were swollen and he had them raised on a foot stool. He said he gets dizzy when he stands, so he rises slowly. Due to his increased weakness, he said he avoids any activities other than moving from his bed to the living room.”
Document your plan for further addressing the patient’s needs.
For example, “Chaplain will visit patient next week to further facilitate a legacy project and will continue to assess his and his wife’s needs.”
Here is an example of a bad documentation and yet it’s common among chaplain documentation.
Patient smiled and greeted chaplain upon arrival into patient’s room. Talked about her husband and family members while holding chaplain’s hand. Chaplain provided a ministry of presence, prayed with patient, and provided a follow-up phone call to the daughter. Patient denied pain and appeared comfortable.
From reading this note, do you know the hospice diagnosis? Do you know why this patient needs hospice care? Is the patient eligible for hospice services? Why would Medicare pay for this patient’s hospice care?
In reality, this patient could not maintain posture without supports; was unable to maintain a reality-based conversation even though she smiled upon the chaplain’s arrival; coughed after the hospice aide finished feeding her; needed support pillows and was leaning to the side; and stared through the chaplain rather than actually “greeting” him.
What is the correct way to document this visit?
Data: Patient was received in her wheelchair, leaning to her left side with support pillows as aide was completing feeding her lunch. Patient was coughing after eating and stared into space.
Care plans being addressed: altered mental status and spiritual support.
Action: Chaplain greeted patient, held her hand, encouraged eye contact, read scriptures and prayed with patient.
Results: When chaplain brought up husband’s name, patient began to talk about him as if he were still alive, although he has been deceased for years. Patient appeared comforted by prayers and scripture reading as evidenced by calm affect and closed eyes.
Observations: Patient coughed after mealtime, leaned to side, and was unable to engage in reality-based conversation.
Plan: Chaplain will visit patient in two weeks to provide spiritual presence and will phone patient’s daughter to offer support for anticipatory grief.
Hospice Chaplaincy is a national 501 (c)(3) nonprofit organization committed to the belief that people from all backgrounds, cultures and faith traditions should experience the end of life in a way that matches their own values and goals. The task of dying is complicated and often confronts us with lots of emotional and physical suffering. Hospice Chaplaincy is dedicated to providing patient advocacy, support, and education services to the public, to create a cultural shift to inform and transform our thinking around the end of life.