Why Quantifiable Information Matters in Defensible Documentation
Presented by Ellen R. Strunk and Maureen McCarthy
Nonfinancial: Ellen R. Strunk and Maureen McCarthy have no competing nonfinancial interests or relationships with regard to the content presented in this course.
The implementation of the Patient-Driven Payment Model (PDPM) presents a new landscape for SNF documentation requirements. Clinicians have a lot to learn about what is expected by payers and reviewers alike. Defensible documentation doesn’t always mean more documentation. It means documenting more effectively. This course will discuss key components of documentation for the entry- and intermediate-level nurse and therapist, including key components of a comprehensive assessment, the importance of gathering objective information initially and throughout the episode of care, and the impact of the Minimum Data Set.
Meet your instructors
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…
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,…
Chapters & learning objectives
1. Principles of a Comprehensive Assessment
This chapter will present the key components of a nursing assessment and a therapy assessment. The concepts of skilled, reasonable, and necessary will be articulated in terms nurses and therapists will understand. The importance of creating a clearly defined plan of care with interprofessional goals and strategies is critical to ensuring documentation is defensible to anyone reviewing it.
2. Capturing Objective Information
Collecting key pieces of objective information is an important task for nurses and therapists alike. The information collected helps to put the pieces of the resident’s care plan into place and supports the medical necessity of the interventions. Payers expect to see measures that are standardized and have some predictive or other clinical value. This chapter will share examples of objective tools and assessments and how to integrate them into the documentation.
3. The Role of the Minimum Data Set
The Minimum Data Set (MDS) is the foundation of the resident assessment process in a skilled nursing facility. This chapter will explain the fundamental parts of the MDS, its role in reflecting patient care, and its connection to payment.
More courses in this series
Fundamental Concepts of Defensible Documentation
Maureen McCarthy and Ellen R. Strunk
Patient-Centered Defensible Documentation
Maureen McCarthy and Ellen R. Strunk
Why Quantifiable Information Matters in Defensible Documentation
Maureen McCarthy and Ellen R. Strunk
Interprofessional Collaboration in Defensible Documentation
Maureen McCarthy and Ellen R. Strunk
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