Developing Documentation in PowerChart for a Transitional Care Unit
By Donna Zelock

While working in a multi facility organization, I was asked to develop a PowerForm for the MDS Coordinators in a Transitional Care Unit. I had two immediate questions: What is a Transitional Care Unit and what are the responsibilities of the MDS Coordinator?

The Transitional Care Units provide care for patients who were no longer eligible for the acute care provided by the hospital and had not met discharge criteria. The patient is discharged from the acute care setting and readmitted into Transitional Care for a period of up to 90 days.

The MDS coordinator is responsible for submitting accurate documentation to the state to ensure optimal reimbursement is maintained. MDS refers to “Minimum Data Set.” Each state has guidelines for reimbursement based on the completion of a MDS form.

After meeting with several MDS Coordinators, a workgroup was formed. The members included the MDS Coordinators, Nurse Mangers, staff nurses and me - a senior Systems Analyst/Consultant.

The workgroup objectives included:

• Identify the needs of the Transitional Care / MDS Coordinator to complete documentation.
  • Complete a gap analysis of the current PowerChart documentation.
• Provide adequate documentation tools
  • Multidisciplinary documentation
  • PowerForms
  • Charting Flowsheets
• Recommend a design approach consistent with the standards of the organization.
• Validate that the documentation matches with the workgroup recommendations and expectations.
• Adhere to a strict timeline, in this case, 14 weeks.

The kickoff meeting and all subsequent meetings were scheduled via conference calls and demonstrated via a webinar tool. We began with introductions followed by a discussion of current systems. Group member roles and responsibilities were identified and samples of current documentation were gathered. Bi-weekly meetings were established with an agenda and meeting minutes were updated for each meeting.

Technology challenges included an introduction to PCs (using e-mail, webinar tools, etc.) for those who were not familiar and comfortable with computers. An introduction to Cerner (the look and feel of PowerForms, Charting Flowsheets, etc.), and a discussion about security, who can access the forms, charting flowsheets, etc. and how they will be accessed.

(Note: Because Cerner was being installed, this involved some special support, often individual sessions, to promote comfort and confidence to move forward. Generally, each meeting began with a review of the system and what had been done as a result of the previous meeting.)

The MDS Forms are generally submitted to the state on day 14, day 30, day 60, and day 90. If the diagnosis changes during the patient’s stay, the forms are re-evaluated and resubmitted on new guideline dates.

The documentation included identification information, demographic information, customary routine information, Face Sheet information, Cognitive Patterns, Communication/Hearing Patterns, Vision Patterns, and many other categories. The MDS Coordinators stressed the importance of having the exact wording from the MDS Form translated to the PowerForm. There could be no room for guesswork or interpretation because it could offset the acuity of the patient and therefore, might result in a lower reimbursement.

The MDS questions and answers were placed on an Excel spreadsheet. Each question was reviewed by the workgroup in order to determine what should be included in documentation and who would chart the information. Guest members were included as we approached various sections of the forms. For example, Social Workers, Dieticians, Occupational Therapists, etc.

A small amount of documentation would be performed by the PCAs (Patient Care Assistants). This was a new approach because, in general, PCAs do not document in PowerChart. We carefully reviewed the questions and answers, making sure the PCAs would not be making decisions, only observations. For example, a PCA might document whether basic needs were met independently by the patient or if supervision was required. The PCA could also document bathing and performances and range of motion. They would not be documenting items such as short term memory, modes of expression, and speech clarity, which are part of nursing documentation.

Once the items of documentation had been decided and developed, the MDS Coordinator could go back and look at the last seven days (or another designated time frame) and determine the highest day of acuity to be submitted for reimbursement. After completing the documentation forms, a charting flowsheet was developed. This was accomplished by enlisting the Security Team to create a tab in PowerChart and adding eligibility to the PCAs security. The same steps were followed to create documentation for the Transitional Care nurses and the MDS Coordinator. The advantage of the Charting Flowsheet was ease of documentation, minimal training, and the fact that results could be viewed easily over a period of time (example: 1 week, 30 days, etc.). Viewing of results enhanced the accuracy for the gathering of information by the MDS Coordinator.

Some challenges included adding Last Charted Values to all DTAs with static information to promote ease of documentation. The nomenclature of some already established DTAs needed to be revisited to reflect the MDS Form and subsequently submitted through change management for approval.

Pros and Cons:

Some Pros of Transitional Care Documentation include:

• An accurate reflection of MDS Documentation Forms
• A Multidisciplinary approach to documentation
• Incorporates nursing and PCA documentation with end-user buy-in
• Last charted values expedite documentation time

Some Cons of Transitional Care Documentation include:

• Duplicate charting by the MDS Coordinator (once charted in PowerChart, it needs to be transcribed into the MDS System)
• Triggers on the MDS Form are not captured
• A plan of care is not automatically initiated
• Maintenance is required when the MDS Form changes

Customer satisfaction was achieved. Some key factors to success included listening to what the workgroup had to say, adequate planning and preparation, continuously reviewing what has been discussed such as design decisions, demonstrations of the product in process, and remaining flexible to make changes as required. Additionally, we met the needs of the end user, increased compliance, and created healthier outcomes for the patient.

If you would like more information please email vcs@getvitalized.com or call 610.444.1233.