Defensible Documentation

Question 1

Top 10 Payer complaints about documentation?

Answer 1

1. poor legibility
2. incomplete documentation
3. no documentation for date of service
4. abbreviations- too many, cannot understand
5. documentation does not support the billing
6. does not demonstrate skilled care
7. does not support medical necessity
8. does not demonstrate progress
9. repetitious daily notes showing no change in patient status
10. interventions with no clarification of time, frequency, duration

Question 2

documentation should…

Answer 2

-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

Question 3

top 10 tips for documentation

Answer 3

1. limit use of abbreviations
2. date and sign all entires
3. document legibly
4. report functional progress towards goals regularly
5. document at the time of the visit when possible
6. clearly identify not types
7. include all related communication
8. include missed or canceled visits
9. demonstrate skilled care and medical necessity
10. demonstrate planning throughout for the conclusion of the episode of care

Question 4

Including the patients participation restrictions, activity limitations, and body function and structure is including what exactly in your documentation?

Answer 4

ICF terminology

Question 5

With activity limitations what should the skilled based assessment consider with the patient?

Answer 5

-consistency
-flexibility
-efficiency

Question 6

payers often jump to what section on documentation?

Answer 6

assessment

Question 7

what is some terminology for skilled interventions

Answer 7

-analyze
-assess
-direct
-education
-implement
-modify
-revise
-progress
-teach

Question 8

what is some terminology for unskilled interventions?

Answer 8

-supervise
-monitor
-observe
-maintain
-practice

Question 9

Are outcome measure alone goals?

Answer 9

no

Question 10

What is something you should do for 3rd party payers?

Answer 10

document the use of outcome measures

Question 11

What are SOAP notes important for?

Answer 11

-legal documentation
-3rd party payment
-a record for the other therapists working with your patients
-facilitates clinical decision making