Defensible Documentation Flashcards
Top 10 Payer complaints about documentation?
- poor legibility
- incomplete documentation
- no documentation for date of service
- abbreviations- too many, cannot understand
- documentation does not support the billing
- does not demonstrate skilled care
- does not support medical necessity
- does not demonstrate progress
- repetitious daily notes showing no change in patient status
- interventions with no clarification of time, frequency, duration
documentation should…
-clearly demonstrate the pt story
-justify that services provided were medically necessary
-proves pt’s condition warranted your skilled intervention
-demonstrates the proper quality of care given
top 10 tips for documentation
- limit use of abbreviations
- date and sign all entires
- document legibly
- report functional progress towards goals regularly
- document at the time of the visit when possible
- clearly identify not types
- include all related communication
- include missed or canceled visits
- demonstrate skilled care and medical necessity
- demonstrate planning throughout for the conclusion of the episode of care
Including the patients participation restrictions, activity limitations, and body function and structure is including what exactly in your documentation?
ICF terminology
With activity limitations what should the skilled based assessment consider with the patient?
-consistency
-flexibility
-efficiency
payers often jump to what section on documentation?
assessment
what is some terminology for skilled interventions
-analyze
-assess
-direct
-education
-implement
-modify
-revise
-progress
-teach
what is some terminology for unskilled interventions?
-supervise
-monitor
-observe
-maintain
-practice
Are outcome measure alone goals?
no
What is something you should do for 3rd party payers?
document the use of outcome measures
What are SOAP notes important for?
-legal documentation
-3rd party payment
-a record for the other therapists working with your patients
-facilitates clinical decision making
