Information Overload? A PDPM Admission Checklist

In a prior BKD Thoughtware® article, we discussed requesting information from referral sources prior to a skilled nursing facility (SNF) admission. Under the Patient-Driven Payment Model (PDPM), obtaining and researching the hospital record information prior to completion of the initial five-day minimum data set (MDS) is very important for not only MDS accuracy but also appropriate reimbursement. A sample tool was included with the prior article that included items a SNF would want to request prior to admission. Some may question the need to obtain the information included on the tool.

Under the PDPM, SNFs are required to complete an MDS assessment with an assessment reference day of any of the first eight days of the patient’s stay. The PDPM is based on patient characteristics instead of the prior Resource Utilization Group (RUG) system that focused primarily on the number of therapy services provided to the patient in the seven-day look-back period. The MDS was originally developed to assist SNFs in development of a comprehensive plan of care for each individual patient. Fast-forward to the Prospective Payment System (PPS), and it also became a tool used to determine payment for skilled care under the RUG system. MDS accuracy is key to not only development of a comprehensive plan of care but appropriate reimbursement. Including all current clinical information on each completed MDS should be top of mind for SNF providers.

Determining what information from the hospital records should be included on the MDS assessment depends partially on why the patient is receiving skilled care and services. The hospital information obtained prior to and upon admission should provide the SNF with not only diagnosis information but also medication, treatment and surgical and test results. Researching the hospital medical record will provide a foundation on which to build each patient’s care plan. Understanding each patient’s medical history, chronic conditions and acute conditions, as well as medications and treatments during the acute stay, should provide the SNF with valuable information regarding current and potential patient problems. Development of a comprehensive plan of care for each skilled admission provides valuable insight to the nursing staff who are caring for each individual patient.

The hospital history and physical(s) (H&P), discharge summary and diagnosis list are helpful as the SNF determines the primary reason for the skilled stay. The primary reason for skilled care is the diagnosis code that is entered in section I0020B on the MDS assessment. Once the SNF determines the primary reason for skilled care and maps that specific diagnosis to one of the 10 clinical categories under PDPM, the stage is set to populate the remainder of the MDS with accurate information. 

Medication Administration Records (MAR), Treatment Administration Records (TAR), respiratory therapy records, IV fluid or tube feeding records and transfusion records, along with surgical reports and lab, radiology, pathology and other test results, provide information that may be helpful in determining other actual or potential patient problems that should be addressed in the care plan and monitored during the skilled stay. Wound reports and therapy documentation from the hospital can assist the SNF in determining what skilled care and services will be needed following admission. Dietary assessment, intake and output records and nutritional intake forms can provide insight regarding each patient’s nutritional and hydration status. The social service assessment and discharge planning notes from the hospital are helpful in determining emotional needs as well as any issues with behaviors. 

Once the hospital medical record information is reviewed, it also will be important for the SNF to document a detailed prior level of function for each patient admitted for skilled care and services. When SNF providers have a detailed prior level of function that includes not only self-care activities but also domestic tasks like meal prep, light housekeeping, laundry, yard maintenance, paying bills and managing finances, this can provide a detailed picture of where each patient was before becoming ill or injured. Understanding the patient’s prior level of function also provides insight to what services may be needed upon SNF discharge, which is important for the discharge plans that should be initiated upon admission.

Now that the medical records from the acute stay have been reviewed and the SNF has determined a patient’s prior level of function as well as current functional limitations, the care planning process can begin. Development of a patient care plan should be interdisciplinary and thought of as instruction to the nursing staff regarding each patient’s individual care needs and monitoring. 

Most patients admit to skilled care with numerous comorbidities and problems. Accurate MDS completion requires attention to detail. Frequent conversations with physicians and their extenders will be critical to obtaining appropriate specific diagnosis information. The attention to detail prior to and during the admission process regarding medical record review should allow SNF providers to develop a more comprehensive plan of care to help move patients toward their optimal level as quickly as possible.

Please see the sample interdisciplinary team (IDT) checklist we have developed to assist SNFs in collecting needed information for each patient prior to and upon admission. If you have questions, please reach out to your BKD trusted advisor or use the Contact Us form below.


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