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improve your documentation immediately by Following these simple guidelines
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| Most SNFs provide the care the resident needs at the appropriate time, but struggle with communicating and recording the care on the MDS in order to trigger a higher case-mix level and corresponding reimbursement.
Here are a few tips to ensure more accurate documentation:
DO: -
Document concisely and factually, using precise language -
Start each entry with the date and time -
Document only issues/information related to patient care
DON’T: -
Offer your opinions; instead, discuss observations (i.e., replace “resident slept poorly” with “resident was up walking in hall six times between 3 a.m. and 5 a.m.”) -
Repeat information that is stated elsewhere in the health record, such as on a flow sheet -
Discuss staff or departmental relationships in the document
For step-by-step methods of improving collaboration between departments through documentation, order Nursing Therapy and Documentation: Optimizing SNF Regulatory Compliance and Quality Resident Outcomes.
This book goes how to ensure the full scope of resident care is documented and identified, letting the facility receive the payment it deserves. |
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