Software and Services for Home Health, Hospice and Healthcare Facilities

Denial-Proof Documentation

Lisa Jenkins, MPT, BBA, President, Physical Therapy Consultant
This presentation will provide an overview of the importance of documentation and the documentation process.

  • 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

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