Documentation Revitalized: Maximize Reimbursement with Tips for Skilled Therapy, Daily Notes, and Defensible Documentation

DOCUMENTING SKILLED THERAPY & THE DAILY NOTE

Identify Your Role and Scope of Practice in the Delivery of Services and Documentation

• Demonstrate skill, necessity, and value
• What’s trending in today’s healthcare settings
• The EMR factor
• If it’s not documented, it hasn’t been done
• Investigate reasons for denial
• Establishing roles - therapist or caregiver?

Prior Level of Function

• Set the stage “once upon a time”
• Fundamental components to justify services
• Supportive language for medical necessity

Identify and Write Obtainable Patient Goals

• Select the best plan of care to achieve patient progressions
• Comparison to the goals
• Tackling progress notes
• Treatment selection and effectiveness
• When to make modifications

Clinical and Documentation Expectations

• Purpose of documentation
• Key aspects and common pitfalls
• Select activities and services that are reasonable, necessary and valuable
• Specific expectations and documentation requirements (for inpatient rehab, SNF, home care, outpatient)
• Write effective and accurate progress reports third party payers understand

Create Defensible Documentation

• Provide appropriate documentation of skilled necessity of care
• How to ensure coverage for all payers
• Demonstrate reasonable and necessary/skilled services
• Importance of functional outcomes and requirements

Components of Quality Documentation

• Purpose and expectations
• Body structure, activity limitations, and participation
• Identify patient problems –subjective
• Measure and treat problems – objective
• Assess progress, changes, and recommendations – assessment
• Develop future care – plan