Denial-Proof Documentation

This presentation will provide an overview of the importance of documentation and the documentation process.

Objectives:

• Understand the purpose of documentation regarding patient illness or injury, plan of care, and clinical justification for skilled treatment intervention.
• Understand the documentation process.
• Define component parts and requirements of the therapy evaluation.>
• Discuss patient-specific interview questions to develop various component parts of the evaluation and pertinent patient information.
• Understand requirements for identifying objective measurements regarding Transmittal 63 and the use of informal and standardized assessment instruments.
• Determine how to devise a treatment plan.
• Understand and develop key elements and requirements of the daily encounter note.
• Define elements and requirements of progress notes and re-certifications.
• Develop component parts and requirements of the discharge note.
• Discuss requirements of patient screens in a SNF.
• Determine required elements of patient orders.
• Define regulations and requirements for group/concurrent treatment related to:
  • Medicare part A
  • Medicare part B
  • Documentation
  • Billing