ExpiredDefensible Documentation for Nursing & Therapy

  • November 20, 2014
    12:00 pm - 1:30 pm

The ability to create defensible documentation that clearly and concisely supports medical necessity continues to challenge all disciplines providing care in home health. Although specific attention keeps therapy services in the cross hairs of denials, audits efforts clearly indicate that the deficits being used to deny payment are seen just as often in nursing notes as well. Many clinicians are quick to lay a degree of blame on the documentation tools they are given to use. Both paper and electronic options are far too often held more accountable than the person competing the form and actually responsible for the content.

Many home health veterans and tool developers have the battle scars of trying to change documentation tools as there never seems to be one that fixes the problems completely let alone make everyone happy. The focus has been on the end product of content and attempts to find fixes that actually decrease clinical decision making by relying heavily on check boxes or drop down choices.

This series of four webinars will create a change in how clinicians think about documentation by peeling back layers of myth and unclear directions and getting back to the very foundational components of good content creation- subjective information, objective data, assessment of patient response and performance and planning for ongoing care. The necessary level of content is driven by the clinician having the right focus and not a new form.

 Series Topics

Each session will build upon the previous session and will use SOAP charting as its foundation.

Session 1: Thursday, November 6- 12-1:30 pm
Subjective Documentation

Session 2: Thursday, November, 20- 12:1:30pm
Objective Documentation

Session 3: Tuesday, December 2- 12-1:30 pm
Assessment Documentation

Session 4: Tuesday, December, 16- 12-1:30pm
Plan Documentation

If you have any questions, please contact Chloe Roe at croe@homecarenh.org, or call 603-225-5597

Documentation Series Registration


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