Quality Documentation Tips

Tobacco Screening & Cessation Reminder / Change

  • Please remember to screen for tobacco use, not just smoking.
  • We are now scored on whether teaching was done at the most recent visit where there is documentation of current tobacco usage.
  • Cessation teaching must be done by the provider at every visit where it is documented that the patient is a current tobacco user. THIS IS A CHANGE FROM PREVIOUS YEARS.

Depression Screening & Follow Up Plan

  • The screening must be referenced in your Assessment & Plan and noted to be “positive” or “negative.”
  • For negative screenings, it is acceptable to simply state that the screening is negative.
  • For positive screenings, a follow-up plan must be documented.

Questions? Contact Janell Sauder, Quality Improvement Nurse Coordinator, at jsauder@augustahealth.com or (540) 245-7564.