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Fundamentals of Effective Hospice Documentation

presented by Cathleen Armato, RN, CHC

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Disclosure Statement:

Financial—Cathleen Armato is a shareholder with Armato & Associates, LLC, a health care consulting company. Cathleen Armato receives compensation from MedBridge for the production of this course.
Nonfinancial— No relevant nonfinancial relationship exists.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

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Video Runtime: 45 Minutes; Learning Assessment Time: 30 Minutes

The clinical record is the most reliable source of information in ongoing medical care and quality improvement, defense of claims, and any legal proceedings. Unfortunately, documentation frequently omits significant parts of the care and efforts of the hospice team. Complete and accurate documentation can support positive outcomes for the patient, the organization, and the clinician. Interdisciplinary team members with a strong understanding of the purpose and use of the clinical record and required documentation are better positioned for success and for supporting positive outcomes. This course reviews best practices in documentation, the use of evidence-based tools, the dynamic terminal diagnosis, and special situations with specific documentation requirements.

Meet Your Instructor

Cathleen Armato, RN, CHC

Cathleen Armato is an experienced executive with 22 years in the home care and hospice industry. She has served in various roles during that time, including VP of operations and chief compliance officer for a nationwide healthcare provider. In 2012, Cat became a consultant. Since that time, she has assisted multiple organizations with their compliance…

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Chapters & Learning Objectives

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1. Introduction to Effective Documentation

The clinical record is considered the most reliable account of care, yet clinicians seldom have their contributions to health care recognized, in part due to inadequate documentation. This chapter reviews the importance of accurate and complete documentation to the health care community, the organization, and the clinician specifically.

2. Documenting Eligibility for Interdisciplinary Team Members

Terminal diagnoses are dynamic in hospice, meaning they can and do change over time. This chapter reviews common diagnoses, Medicare’s view of the terminal diagnosis, the use of eligibility guidelines in complete and accurate documentation, and the use of standardized and evidence-based tools.

3. Telling the Story

Team members accomplish a lot in a brief visit. Does the documentation support all of the efforts, actions, and results of care? This chapter reviews the significance of telling the complete story of the patient and the visit.

4. Situational Documentation

Transitions of care, higher levels of care, discharges, revocations, and other changes are critical times in patient care and safety. This chapter reviews these specific situations and the documentation requirements and recommendations surrounding these risk areas.

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