Charting by exception is the single most problematic form of nursing charting. Charting by exception is a tool used for residents who require little to no nursing intervention or care. This type of charting, if not done correctly, will leave the facility subject to allegations of RUG review errors. Reviewers scrutinize nurse charting to determine if it supports flow sheets and checklists. Since MDS 3.0 requires clearly documented comments, charting by exception will be a basis for allegations of RUG errors.
Charting by Exception – the requirements.
To minimize allegations of RUG errors, each resident should have a well-documented resident health baseline and a detailed Plan of Care. Proper charting by exception requires that a chart note directly address the Plan of Care and the documented resident baseline of health in all its elements. This charting must be done for any change, no matter how minor. Writing “resident doing well at this time” is not sufficient.
If the facility is charting once a shift on an independent resident, the chart note must address every single aspect of the Plan of Care. This means everything from diet to skin care must be addressed in the chart note. It also means any exception to a well-documented and established health baseline, no matter how minor, must be charted and must tie in to the Plan of Care. For a resident with far more care needs, charting by exception becomes overwhelmingly time consuming and almost impossible to achieve.
When charting by exception isn’t charting
Mr. B is a completely independent resident. The previous 9 months of charting comprises a single entry, once per month that states “resident doing well at this time.” Mr. B is found in his room crying. The CNA talks to him for a few minutes and determines it is the anniversary of his Uncle’s death. The resident seems to calm down and the CNA makes no mention of the incident. Two weeks later a chart note states “Resident doing well at this time” and maybe a few recorded vital signs. Two weeks after that he leaves the facility unannounced and does not return. The nurses call the police and a search ensues. He is found several miles away attempting to board a bus and states to the Police, “No one at that place cares about anything, I just want to die.”
The resident’s family then institutes a lawsuit. The facility is now in the position of having to prove they addressed this resident’s emotional well-being, health and safety. With these chart notes as “evidence” the facility will have difficulty defending against this lawsuit. If an ARD happens at the same time and the MDS nurse codes for elopement that will cause allegations of a RUG error as well.
Charting and Rug Errors
Charting by exception requires everything not in the documented and established base line to be charted. In RUG reviews we have seen nurses charting that the Physician was in to see the resident. This is not an exception to the baseline providing it is a normal “checkup” visit. However, the MDS nurse does not see this note since it should not have been in a nurse note. The MDS nurse, who did not reviewing nurse charting, does not give credit for that Physician visit and creating a potential allegation of a RUG error.
Reviewers scrutinize nursing notes to determine the existence of a basis to support ADL and other “checklists” that are used for MDS coding claims. If a nurse note claims “resident doing well” and another document indicates differently, that will be labeled a RUG error. Any document that disagrees with another document in the resident chart is a basis for allegations of a RUG error. All documentation in the resident chart must agree, meaning, the same thing is being charted on every document. If a nurse charts, “resident limping, required assistance to chair” but on the same day PT wrote, “resident improving rapidly, requires no assist to chair”, a RUG error will be alleged because two documents give two outcomes.
Reviewers look for these elements of disagreement and find them.
MDS 3.0 requirements
MDS 3.0 requires that all items noted on the MDS have clear examples. This does not mean putting a check in a box. For example, if a resident has a base line including physical behaviors directed at others, MDS 3.0 requires there be documented examples of this behavior. This means that although the baseline exists for these behaviors, the behaviors must be documented to support the MDS. Charting by exception poses risks to the facility in this scenario.
All MDS 3.0 documentation must have daily documentation supporting any frequency claims, programs such as toileting or physical therapy, behaviors, cognition and ADL. A simple check box will no longer suffice.
To protect your facility from large recoupments, all nurses must be trained in charting by exception if it is used in the facility. MDS 3.0 dictates much documentation must be available to reviewers. Unless your nurses are charting correctly, those notes will become the basis for alleged RUG review errors.
Next week: Three Ways to Prepare for RUG Reviews.
