Fundamental Concepts of Defensible Documentation

Presented by Ellen R. Strunk and Maureen McCarthy

Video Runtime: 45 Minutes; Learning Assessment Time: 24 Minutes

It is often said, “If it is not documented, it was not done.” This cliché, while true, often triggers frustration in clinicians struggling to keep up with documentation. Poor documentation has many costs for SNF providers, including lost time and lost money. Poor documentation is a drain on the morale of nurses and therapists and is more likely to portray the wrong message about the value and quality of care delivered in a skilled nursing facility. Yet the challenge for many new to intermediate-level clinicians is that documentation standards and coverage criteria frequently change, making resident care even more complicated. This course will examine the technical and clinical criteria for skilled nursing facility coverage and the core principles of documentation. Armed with a fundamental understanding of this information, clinicians will be able to meet documentation expectations.

Meet your instructors

Person with long blonde hair, smiling in a red top, against a gray background.

Ellen R. Strunk

Ellen R. Strunk has worked in various roles and settings as a clinician, manager/director, and policy expert. Ellen is an expert at helping customers understand the Centers for Medicare & Medicaid Services (CMS) prospective payment systems in the skilled nursing facility and home health settings, as well as outpatient therapy…

Read full bio

A smiling woman with long brown hair in a pink top represents medbridge's vision for digital healthcare.

Maureen McCarthy

Maureen is the president of Celtic Consulting, LLC, a clinical reimbursement, clinical operations, and compliance advisory firm. She is also the CEO of MDSRescue, an organization that provides temporary MDS completion services across the country. Recognized as an industry leader in clinical reimbursement for long-term care,…

Read full bio

Chapters & learning objectives

1. Why This Course Matters

Our current health care environment is evolving. Some would call it a period of disruption. As providers, we must ensure our documentation accurately provides the right picture of the patient, such as an accurate diagnosis and an accurate description of the skilled services the patient needs. If we do this, we can do our part in ensuring policymakers have the right data upon which to make decisions.

2. Key Definitions to Articulate

The Patient-Driven Payment Model has taught us that in order to get an accurate and appropriate picture of the patient’s needs, there are key pieces of information that must be collected. The Medicare manuals provide examples of what skilled nursing and therapy services are. But just writing these terms down on a piece of paper does not make them skilled services. This chapter will help clinicians articulate what those terms mean in the day-to-day life of a nurse and therapist.

3. Qualifying Criteria for Skilled Care in Medicare Parts A and B

Clinicians who work in skilled nursing facilities need to have a basic understanding of the various parts of Medicare their residents may have access to. There are key similarities between the Part A and Part B Medicare benefits in a SNF, and there are also differences. The purpose of this chapter is not to provide a deep dive into the nuances of the Medicare program, but to provide an overview of the Medicare Part A and Medicare Part B benefits in the skilled nursing facility so nurses and therapists have a context as we talk about documentation requirements.

More courses in this series