All levels of Long Term Post-Acute Care (LTPAC), including Skilled Nursing Facilities (SNF), Senior Living communities, Home Care, etc. must be able to substantiate they are providing the care required by their patients.  Way back when I was a nursing assistant there was a constant chorus of “if it’s not documented, it was not done” and then in nursing school and while working as a nurse the chorus became even louder.  

Documenting care and documenting care correctly are not always the same.  All too often, the focus is placed on ensuring care is documented rather than ensuring the correct information is documented.  Each facet of the Long Term Post-Acute Care model should be reviewing documentation to confirm the documentation is accurate, not simply that documentation exists.  Documentation of Activities of Daily Living (ADLs) has been a constant challenge,  especially in Skilled Nursing.

Tips for Ensuring Activities of Daily Living is Documented Correctly

In an SNF, reviewing ADL documentation should be thorough and frequent.  A yearly review of ADL codes and their meanings is not enough!  Here are some questions SNF providers should be asking themselves:

• How often have you reviewed what has been coded versus checking that something was coded?
• How often are you talking to your staff about ADLs and documentation?  
• Have you recently reviewed your ADL documentation process for possible improvements?  
• Do you have an electronic ADL documentation platform?
• Which electronic ADL platform is utilized in your facility?
• If you do have electronic ADL documentation, how is documentation recorded during an electricity or internet outage?
• How soon after admission does your staff documenting on the ADLs of resident?
• How often is ADL coding completed?
• How are your leaders educating the staff when coding discrepancies are identified?

A great place to start when attempting to tackle accurate ADL coding is education.  Education on ADLs and documentation should not mean handing nursing aides a multiple choice or fill-in-the-blank test.  SNFs may benefit from designating several “ADL Superstars”.  The “ADL Superstars” should have an excellent understanding of the MDS 3.0 Resident Assessment Instrument’s (RAI) definitions on ADL documentation.  The “ADL Superstars” do not have to be members of the management team; in fact, it is often less intimidating to ask a coworker a question.  Facilities need to have resources for each shift when it comes to ADL coding because coding questions do not only come up on day shift.  Educate the staff and review the results.   Determine the areas that have improved and which areas still require improvement.  Your staff will benefit from the extra education.

Reviewing your current ADL document process is essential to appropriate coding.  Is the current process easy to navigate and understand?  If not, all of the education in the world may be a wasted effort.  Utilizing an electronic ADL documentation platform such as the PointClickCare® ADL documentation solution Point of Care® may improve accuracy and speed of ADL documentation.  The solution from  PointClickCare®  offers providers the ability to customize ADL documentation to the facility’s need while remaining within the guidelines from the Centers for Medicare and Medicaid Services (CMS).  Point of Care® is user-friendly and offers real-time reports on the documentation entered.  

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