For a facility to be classified as an inpatient rehabilitation facility (IRF), Medicare requires that the facility provide 24-hour rehabilitation nursing. Documentation is important because it helps determine the most appropriate site for the provision of care. Functional assessments are ongoing and should provide information about patients and which interventions are most appropriate; this allows for successful achievement of rehabilitation goals. Nurses must define the elements of a quality assessment based on the individual patient and then monitor findings and respond appropriately. Reimbursement is supported by measuring functional outcomes based on the initial assessment of patients. The final reimbursement, based on possible denial of a claim, is supported by documentation of the functional outcome in the medical record. Medicare contractors cannot observe the everyday interventions nurses use with patients, so they require documentation as proof. This article features examples of documentation that nurses can use to help meet the expectation of 24-hour nursing. Following through with these suggestions will not only help provide proof of 24-hour nursing, more accurate reimbursement, and the security of a full reimbursement, but ultimately will ensure quality rehabilitation services and care for patients.

Medicare policy states that it is reasonable and necessary for patients to be cared for in a rehabilitation setting if they need coordinated care with multidisciplinary involvement or have comorbidities along with their primary diagnosis. The Medicare agreement can be broken if it is determined that a hospital does not provide 24-hour nursing service as a requirement for participation (Centers for Medicare & Medicaid Services [CMS], 2006). There is no doubt that nursing is an intricate and nonnegotiable part of the regulatory requirements.

One of Medicare’s conditions of participation for a facility to be classified as an IRF is 24-hour rehabilitation nursing. Functional assessments should be ongoing to provide patient information that promotes appropriate interventions and facilitates the successful achievement of rehabilitation goals. Documentation is an imperative criterion to emphasize that the most appropriate setting for the provision of care is in a rehabilitation hospital. Nursing documentation is essential to the future of effective, efficient inpatient acute rehabilitation. Nurses must provide a quality assessment based on an evaluation of the individual patient, ongoing monitoring of the patient’s condition, and appropriate responses as indicated—all of which must be documented in the medical record. Various comorbidities should be monitored as well. Patients should be educated on these conditions, and documentation should relate how these comorbidities may affect the rehabilitation process (Black, 2007). Based on the patient diagnoses, appropriate reimbursement is supported by measuring the functional independence of the patient, and final reimbursement is supported by documentation of the functional outcome in the medical record.

Nursing documentation that does not support 24-hour rehabilitation nursing can lead, as many facilities around the country have discovered, to unsuccessful audits of medical records by fiscal intermediaries (FIs). FIs have been allowed discretionary measures by CMS to determine compliance with Medicare standards. An FI will examine a medical record to determine whether the IRF has met specified requirements (CMS, 2003). In many cases, these audits lead to the expenditure of large sums of money to appeal claim denials and defend the necessity of rehabilitation stays. Many appeals occur after a patient’s discharge (when documentation already has been completed). Documentation helps determine either reimbursement or denial of payment.

Narrative charting may not be the total answer to FI demands for appropriate nursing documentation, but it certainly can provide a format with which nurses can begin to fulfill necessary requirements. Because Medicare contractors cannot observe the daily interventions and education that nurses provide their patients, they require documentation as proof that an inpatient acute-care setting is necessary and preferred over a less-intensive setting, such as a skilled nursing facility (SNF), or an outpatient setting.

What Is Reasonable and Necessary?

Medicare guidelines tell nurses what they need to do, but the “how to accomplish it” part seems unclear. Medicare does not offer an instruction booklet with specific directions or examples of what to do. At times, the information provided is somewhat vague. It is fair for nurses to expect instructional directives if they are asked to provide documentation justifying 24-hour nursing.

Justly so, Medicare advocates want to ensure payments are accurate and provided to the most appropriate setting and that beneficiaries are given the highest-quality and most appropriate care (CMS, 2001). Monitoring these areas identifies how Medicare dollars are being spent. If auditors compare an SNF nursing note to an acute rehabilitation nursing note and the documentation basically states that care was equitable, then why would Medicare want to pay a bill for a more expensive acute-care rehabilitation stay? An SNF nursing note written during a night shift for a patient with aphasia and known intermittent pain may consist of something similar to “Patient slept well.” In contrast, a nursing note for the same patient written from a rehabilitation nurse perspective may be similar to “Patient closely monitored for signs of grimacing or other noticeable signs of discomfort. Routine positioning was performed; however, pain meds or other comfort measures did not seem to be indicated at this time.”

Another example of night shift documentation is a sleep log. When night nurses assess patients, do they merely document that the patient is sleeping to maintain the continuity of the log? Or does their documentation acknowledge that lack of sleep can have a dramatic effect on endurance, strength, level of confusion, and appetite? Do nurses document how they affect a patient’s level of comfort to promote a good night’s sleep? Documenting this information highlights the effect night nurses can have on how well a patient benefits from therapy and how much they can retain regarding occupational therapy, physical therapy (PT), or nursing education. The key is to document how nursing responds to patient needs in acute-care settings.

According to a report from the U. S. Department of Health & Human Services (HHS; 2007), it is estimated that during 2004 Medicare paid $3.1 billion for patient stays with inadequate documentation. One auditor stated, “It was unclear from the record why the patient could not have been treated in the nursing home” (HHS, p. 15). If documentation does not support an acute rehabilitation stay, Medicare administration may assume the care could have been equally provided in a less-intensive setting. If both settings are documenting identical care (and especially if there is no documented proof supporting an acute-care rehabilitation stay), Medicare would rather pay monies for a less-acute, less-expensive setting.

To become eligible for Medicare reimbursement, specific criteria must be met, and documentation of 24-hour rehabilitation nursing is one such criterion. When the designees for Medicare (such as FIs) review the medical record, they are looking for what constitutes reasonable 24-hour nursing care. They look beyond shift documentation to the entire 24-hour patient picture. Patient interventions and education can only be confirmed if they are documented. For example, auditors may want to know how nursing was responsible for keeping a patient’s skin intact. If a patient with spinal cord injury has intact skin, the following questions could arise:

• Did the patient have extraordinarily tough skin?
• Was the patient simply lucky?
• Was the patient saved from the development of a pressure ulcer because of the meticulous and persistent care of the nurse?

Nurses teach and assist with patient turning, pressure-relief techniques, and nutrition education, and facilitate appropriate follow-up with PT transfer recommendations. Auditors may not recognize that nursing interventions contribute to the absence of pressure sores unless particular interventions are documented.

According to one FI resource (Palmetto, 2006), decision-related support is needed when defining this criteria. A structured decision process with repetitive clear procedures has not been established. CMS manuals provide some guidance, but there are no specific guidelines regarding expectations. It is too vague to simply dirct rehabilitation nurses to document rehabilitation care. Even those nurses who have worked in rehabilitation for years wonder “What exactly is rehabilitation nursing documentation, and isn’t that what we have been doing all along?” Yes, but nurses typically get so busy teaching patients and families that they forget they also have to “teach” Medicare auditors about the care being provided through proof in their documentation. Nurses must find acceptable examples of documentation and support each other with this endeavor.

Some acute rehabilitation facilities have not undergone Medicare audits. Other facilities have experienced probe audits and denials. CMS does not “average” a facility’s performance; instead, it looks at individual patient cases. Although physician documentation is a key to claiming medical necessity, the documentation of all disciplines, including nursing, must demonstrate what has been done to ensure a patient meets the criteria for an inpatient rehabilitation stay.

With Medicare contractors issuing so many denials of reimbursement due to lack of medical necessity information in the medical record, change is inevitable. Change involves vision, incentives, resources, planning, and skills (Pritchett & Pound, 2008). Do nurses have a vision of what is required to keep rehabilitation units open and viable and to keep the rehabilitation industry strong? The following is a list of possible incentives:

• to return patients to the community at their highest level of function
• to have patients show off their relearned skills of speaking or walking when they return for office visits, or to see them approach nurses for a hug (and tears)
• to maintain our jobs and careers as rehabilitation nurses.

What are some resources to help nurses accomplish this vision? Nurses can be their own best resource and, at the same time, worst adversary. Nurses need to be taught how to network and support each other. They need to share the type of documentation that results in the fewest denials, and implement this documentation style on their rehabilitation units.

Some nationally recognized facilities and physicians currently are struggling to create documentation that leads to maximum reimbursement. Being successful in the past does not necessarily predict future success. A road map that points everyone in the same direction, making it easy to do the right thing, would be wonderful. Unfortunately, CMS does not currently provide this detailed roadmap. However, each facility can review its own documentation to see if the following list and creative examples of 24-hour nursing documentation can help to meet regulatory expectations, facilitate more accurate reimbursement, and, ultimately, serve patients by promoting quality rehabilitation services and care.

Documentation Tips

• Eliminate duplicate documentation to save time and energy.
• Establish one place to chart medical evaluations and patient assessments and one place to chart daily functional assessments.
• Chart by exception so medical evaluations can be more of a checklist.
• Use functional charting, which describes a patient’s function and skill level on the 18 items of the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI).
• Medicare requires that admission documentation include a “reasonable” expectation of improvement that will be of “practical” value to the patient for this rehabilitation admission (CMS, 2006). Nurses can chart something similar, such as “There is a reasonable expectation that the patient has high potential to make significant improvement re: staying continent of bowel. A bowel program will be initiated to enhance quality of life and functional ability and to improve chances of patient being discharged to home.” This statement could be used as a template to highlight different aspects of an individual patient’s care, substituting with other needs or goals such as bladder control, safety, or pain.
• Documentation should support communication. Nurses needs to document how they follow through on recommendations made by other disciplines or team members. This fosters the idea of interdisciplinary care and a coordinated program or care team. When writing narrative information regarding functional activities, the burden of care for that period of time should be reflected. There may be times during the day when the patient’s level of care may vary. Clinicians should document only the burden of care at that particular time. Ultimately, if the lowest score of a 3-day assessment period is used, the highest burden of care will be reflected.
• Physicians should identify comorbidities in their history and physical. Nurses’ documentation should reflect these comorbidities and their possible effect on a patient’s rehabilitative efforts. For example, if a rehabilitation nurse knows a patient has a urinary tract infection, this may affect rehabilitation progress by causing fatigue and dizziness and decreasing balance and affecting ambulation, dressing, or other areas of function.
• Nursing narratives should compare what was expected to occur versus what actually occurred regarding a patient’s level of functioning and the ways in which the quality of nursing interventions potentially affected the outcome.
• Some rehabilitation clinicians (e.g., nursing assistants) are better able to account for a patient’s function through a written, narrative description; however, they may struggle to assign an appropriate score. Other clinicians are better suited to convey a patient’s condition with a score. Encourage teamwork; inform clinicians about who is better suited to provide narrative descriptions and “document the [patient’s] story”; then a prospective payment system coordinator or other clinician better versed at scoring can assign the score (Hentschke, 2007).

Narrative Examples

The following are examples of narrative statements that can be based on a patient’s situation. The italicized phrases are interchangeable as appropriate to a patient’s condition/needs (Hentschke, 2007). Note that this kind of template can be implemented more easily in a computerized system, allowing certain words to suit a particular area of concern.

For Safety Concerns

• “Assistance/instruction/or monitoring is needed for dressing, toileting, walking, and balance to help the patient remain free of injury.”
• “Frequent observation of patient required due to knowledge deficit and impulsivity secondary to lower extremity weakness/swallowing difficulties.”

The word assist can be used when a patient is unable to perform a task independently. The word instruct can be used when a patient is able, but not knowledgeable, and needs to be taught how to do something. The word monitor can be used for a patient who is impulsive and has balance or swallowing difficulties. Maintaining patient safety as a priority prevents harm and enhances a patient’s chance to perform at a higher level for all functional skills.

For Pain Concerns

• “Medication/music/calm environment/darkened room/heating pad was provided for the patient to achieve their stated acceptable level of pain.”
• “Patient states pain is now at a tolerable level so that he or she is able to independently put on shirt or assist to put shirt on L arm and pull over head or increase patient’s range of motion to dress independently.”
• “The current medication must be evaluated to recognize the effect it has on diminishing or relieving pain.” The effect of the medication should be documented (i.e., it relieved pain/increased dosage or interval is needed/a stronger pain medication is needed).
• “Turning the patient to a particular side or elevating the head of the bed alleviated or eased the pain.” Documenting these interventions confirms the nurse assessed and addressed the patient’s pain.

Pain can affect a patient in many ways, including level of functioning, motivation, and sleep pattern. The attempt to relieve or decrease pain not only helps make a patient feel better, but also demonstrates the role that rehabilitation nurses assume to facilitate better functional outcomes.

For Skin Concerns

• “Patient required turning q 2 hours/supplemental feeding due to bed immobility and skin breakdown.”
• “To maintain good skin integrity, the patient/family requires assistance/instruction with turning/pressure relief/skin assessment.”

It is important to note whether the patient can turn independently if the family can assist, or if turning needs to be done by staff. Also, the patient may have a specialty mattress assigned on admission. It should be documented whether the mattress, as an intervention, seems effective for the patient’s situation and needs.

For Psychological Concerns

• “Emotional support provided as patient states he is having difficulty coping with stroke, balance, expression, sphincter control (deficit).”
• “Nursing-provided patient and family handouts and brochures for brain injury/stroke support group as recommended by social work and discussed in care team.”

Depression is a predictable comorbidity that decreases a patient’s ability to progress. Nurses should document the ways in which they attempt to get patients to verbalize, or ask the patient to describe the things that are bothersome to them. Depression can complicate the recovery process, keep the patient from making gains, and affect their functional task items.

For Mobility Concerns

• “Nursing provides encouragement to ambulate in room to increase activity tolerance. Instructed to call for supervision or assistance if patient feels weak/unbalanced.”
• “As recommended by PT, nursing instructed patient to continue using walker to facilitate and promote independence. Get feet settled flat on the ground before attempting to transfer.”
• “Due to poor balance, patient was closely guarded while assisted to bathroom. Due to confusion at night, it is necessary for nursing to transfer patient with lifting assistance on to the bedside commode and also back into the bed.”

Nurses are not usually involved with the distance the patient walks, but they need to be concerned about safety and promote skills learned from other disciplines.

For Sphincter Concerns

• “Hard stool noted during bowel program. Requested physician to increase frequency of stool softener.”
• “Patient encouraged to increase PO fluids to upper limit of fluid restriction.” It is helpful to exactly describe the process given to the patient to follow. “Patient was given a schedule at bedside of expected fluid intake per hour to keep him on track of increasing needed fluids.” This type of documentation not only keeps the patient on track, but helps physicians, family members, and other clinicians.
• “Patient has achieved independence in intermittent cath procedure using sterile technique. Patient and mother instructed on clean technique for home bladder program. Nurse provided information on care, management, and ordering supplies for home bladder program.” Nurses should conduct patient education as a patient expands his or her knowledge bases.

For Knowledge-Deficit Concerns

• “Observed patient performing Accu-Chek. Patient continues to require cueing to clean finger with alcohol prior to finger stick.”
• “Patient continues to exceed fluid restrictions. Given recent high bladder volumes, nursing reinforced education on risk of autonomic dysreflexia.”
• “Due to patient’s noncompliance, family has been taught the signs and symptoms of dysreflexia.” It may be necessary for the nurse to note that education must extend to a patient’s visitors and friends, who may go “outside the rules” for their loved one.

For Strength Deficits

• “Patient complains of fatigue after therapy and has difficulty removing pants. Instructed to use the electric bed to sit up and the reacher to facilitate reaching lower legs. With these instructions, patient can remove clothing, but it takes him a little longer than normal.”
• “Patent needs set-up of universal cuff in the a.m.; once cuff is applied, patient independent with eating and grooming.”

For Barrier Concerns

One of the biggest barriers to discharge to home is bowel and bladder incontinence. Nurses need to focus on adjustments that can help patients accomplish their goal of being continent. An experienced rehabilitation nurse can adjust the plan of care as needs change. These changes must be assessed, documented, and communicated to other team members.

• “Family discouraged by patient’s inability to actively participate in bladder program. Educational efforts will focus on patient’s self-cathing technique.”
• “Due to the patient’s significant improvement in the skill sets required for self-cathing, a realistic goal for the patient is to perform independent self-catheterization with set-up of a catheter kit only.”

Additional adjustments will result in tandem with the family’s improved ability to facilitate the patient’s goal of self-cathing once at home.

The cues, suggestions, and education offered to patients demonstrate the importance of 24-hour rehabilitation nursing, but these things often go unnoticed because they go undocumented. Nurses need to support each other as they strive to create best practices. Conversation, observation, or assessments in today’s nursing world do not prove the importance of the nursing role in rehabilitation. Uniform and consistent use of these documentation examples could prove reliable and valid for the rehabilitation nursing requirements outlined in the Medicare guidelines. Rehabilitation nurses must claim their worth by consistently providing appropriate documentation for all patients. If excellent rehabilitation nursing care is given, nurses need to prove it through their 24-hour nursing documentation.

About the Author

Pam Hentschke, MSN RN CRRN, is a clinical nurse specialist for Carolinas Rehabilitation in Charlotte, NC. Address correspondence to her at phentschke@carolinas.org.

References

Black, T. (2007, March 29). The IRF-PPS: Documentation for medical necessity. Uniform Data System for Medical Rehabilitation. Paper presented for Carolinas Rehabilitation, Charlotte, NC.

Centers for Medicare & Medicaid Services. (2001). Medicare program: Prospective payment system for inpatient rehabilitation facility, Final rule. Federal Register, 66(152), 41316–41322.

Centers for Medicare & Medicaid Services. (2003, August 1). Medicare Program: Changes to the inpatient rehabilitation facility prospective payment system and fiscal year 2004 rates, Final Rule. Federal Register, 68(148), 45673–45728. Retrieved February 4, 2009, from http://edocket.access.gpo.gov/2003/03-19540.htm.

Centers for Medicare & Medicaid Services. (2006, February 10). Medicare benefit policy manual. Inpatient hospital services covered under part A; 110.4.2. Retrieved March 4, 2009, from www.cms.hhs.gov/manuals/downloads/bp102c01.pdf.

Hentschke, P. (2007, October 6). 24 Hour Nursing: The proof is in the documentation. Paper presented at the meeting of the Association of Rehabilitation Nursing, Washington, DC.

Palmetto, G. B. A. (2006, March 29). Partners in excellence: Going beyond diagnosis—Documenting reasonable and necessary inpatient rehabilitation facility (IRF) services. Paper presented for Carolinas Rehabilitation, Charlotte, NC.

Pritchett, P., & Pound, R. (2008). Business as unusual: Handbook for managing and supervising organizational change. Dallas, TX: Pritchett Publishing Co.

United States Department of Health and Human Services Office of Inspector General. (2007, June). Consecutive Medicare stays involving inpatient and skilled nursing facilities (OEI-07-05-00340). Retrieved February 3, 2009, from www.oig.hhs.gov/oei/reports/oei-07-05-00340.pdf.