Best Practice for Skilled [Nursing] Documentation in the SNF

Description

Overview

Nurses provide excellent care and services in home care, housing with services and skilled nursing settings. In today’s regulatory world, clinical care must be well documented for the nurses to demonstrate the care and services occurred, and what they were thinking when they provided that care. The quality of your charting (or the lack thereof) can have significant consequences.

Medical record documentation is legally binding. Many staff members including managers get caught up in the requirement to provide a daily note, yet leave behind the expectations of content.  Taking time to explore the medical necessity of each patient will lead the clinical team down the road to exemplary documentation entries and compliant medical records that will withstand contractor medical review.

The key to having pristine medical records lies in the underlying education provided to all staff who contribute to the medical record. Thorough and timely documentation with respect to treatment objectives can help clearly demonstrate a beneficiary’s need for skilled care. Clinical staff must learn how to document medical necessity.  The unique skills of the nurse, therapist, physician and social service clinician must be evident from medical record entries.

This webinar will describe how important critical thinking and creative interventions are in nursing practice, and how to document “best practices.” In order to protect a nursing license, best serve clients and residents, and avoid liability, a nurse must demonstrate good nursing documentation and understand its importance.

Why Should You Attend:

This course will highlight the definition of medical necessity. Clinical managers will gain the knowledge to transition to mindfully crafted notes that serve as a communication tool as well as a historical account for future clinical management.  Learn how to assess if patient evaluations are thorough and the elements are captured within the medical record. Are the daily skills of the licensed professional represented within the documentation? This presentation will highlight tips for training staff to capture the skills provided in a concise manner that is efficient and conveys the critical elements of care. The program will allow Directors and clinicians to establish best practices for thriving documentation patterns and practices.

Session Highlights:

• Medicare Skilled Criteria
• Aspects of medical necessity
• Therapy and nursing documentation expectations for Medicare Contractors
• Defining types of care to document
• Who are the qualified professionals, regulatory guidelines to shape documentation practices

Who Will Benefit:

• Administrators
• Directors of Nursing
• MDS Coordinators
• Nurse Managers
• Nursing Staff
• Therapy Managers
• Occupational Therapists
• Physical Therapists
• Speech Pathologists