consider “fall assessments”, which a nurse uses to determine a patient’s risk of falling while in the hospital – a problem that accounts for 11,000 deaths annually. The assessments ask about medication, mobility issues and confusion, to create a “fall risk score”, which then generates an appropriate menu of interventions.
A nurse could spend 10 minutes documenting a patient’s fall risk, or 10 minutes trying to keep patients from falling. It seems obvious that a computer record of “fall risk” cannot in and of itself prevent falls, but completing those records is considered essential in hospitals. As a result, real fall-prevention efforts – encouraging patients to use the call light, ordering a bedside commode, having an aide do hourly check-ins – get short shrift.
In home hospice, where I now work, the documentation is even more onerous than in the hospital and seems even more disconnected from actual patients. Hospice care is a covered benefit under Medicare, and the United States Centres for Medicare and Medicaid Services maintains rigid standards for documentation. They regularly withhold reimbursement if documentation is deemed incomplete or flawed.
This paperwork might have a good intent – to prevent fraud – but in practice it gives documentary exactitude an outsize importance.
A colleague doing a hospice admission wrote that a dying patient had “liver failure and renal failure” and, in a separate part of her documentation, wrote the conditions in the reverse order: “renal failure and liver failure”. From a medical point of view, the order of the two is irrelevant, but her supervisor reprimanded her for the disparity, since it suggested inconsistency. The concern, of course, was that the hospice would not get paid.
Charting a hospice admission usually takes between two and four hours, and requires filling out a seemingly endless number of data fields – some of them defying logic.
I once had an oxygen-dependent centenarian patient in heart failure seeking admission to hospice.
The hospice physician asked for further proof that the patient met the strict standards for hospice admission. It was a weekend and, during the time it took for me to collect that information, the patient died.
The worst, however, are the health risk assessments done for patients in Medicare Advantage, a programme that pays for coverage under certain private insurance plans. These assessments include an exam, an accurate health history, and diagnosis and documentation of the most serious possible version of the patient’s illnesses. This is known as diagnosis “capture”, and the entire process is colloquially referred to as “upcoding”. Because upcoding classifies these patients as higher-risk medically, Medicare increases the reimbursement given to their insurance companies without requiring that their new, more severe diagnoses be treated in any way.