Date of Graduation
Fall 12-13-2024
Document Access
Project/Capstone - Global access
Degree Name
Master of Science in Nursing (MSN)
College/School
School of Nursing and Health Professions
Program
Kaiser cohort MSN capstone
First Advisor
Catherine Coleman, DNP, RN, PHN, CPHQ, CNL
Second Advisor
Carla Martin, DNP, RN, CIC, CNL, NEA-BC, FACHE
Abstract
Problem: Within the South Bay Hospice Agency, documentation compliance for missed visits was 68% in the first quarter of 2024, when the national standard should be 100% according to the Centers for Medicare & Medicaid Services.
Context: Inadequate nurse documentation and communication between health professionals can lead to medical errors, poor team communication and suboptimal patient outcomes (Tasew et al., 2019). Therefore, the importance of documentation compliance is imperative. Hospice staff perform scheduled visits for terminally ill patients 1-2 times a week; however, a missed visit can occur when a patient declines it for a variety of reasons.
Interventions: The interdisciplinary team and volunteer leadership staff attended two trainings to reinforce agency policy; electronic smart phrase was created to standardize communication; supervisor responsibility was increased to include weekly Electronic Health Record audits.
Measures: The percentage of documented reasons for missed visits per month and the percentage of staff notifying a medical doctor (MD) of a missed visit were tracked through weekly audits.
Results: April was at a 96.55% compliance rate; May at 91.22%; and June at 100%
Conclusions: The patient’s hospice journey must be completely and clearly documented to prevent negative patient experiences and regulatory non-compliance. A multi-faceted intervention including team education, standardized electronic workflow using a smart phrase, and weekly audits are recommended to ensure continuity of care and condition of participation compliance with regulatory agencies.
Keywords: documentation compliance, hospice, missed visits, audits, home care,
communication
Recommended Citation
Felix, Ma Rosalie, "Improving Compliance in Missed Visits Documentation" (2024). Master's Projects and Capstones. 1747.
https://repository.usfca.edu/capstone/1747
