Essential Guide to Medical Record Documentation for the SNF

Why Should You Attend:

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.

Centers for Medicare & Medicaid Service (CMS) establishes laws by which the post-acute providers must abide by. Understanding technical eligibility and practical matter criteria are just two of the essential pieces to the medical record puzzle. The interdisciplinary team has long struggled to coordinate the medical record to support the skilled nature of services provided and allow for consistency in medical descriptors supporting coordination of care.

This course will highlight the definition of medical necessity. 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.

Areas Covered in the Webinar:

• Medicare skilled criteria
• Aspects of medical necessity
• Therapy and nursing documentation expectations for Medicare contractors
• Defining types of care to document
• Jimmo Settlement, who are the qualified professionals
• Regulatory guidelines to shape documentation practices

Who Will Benefit:

• Administrators
• Nurse Managers
• Rehabilitation Managers
• Business Office Manager
• MDS Coordinators
• Nursing Staff
• Social Workers
• Therapists

Elisa Bovee
MS OTR/L, Regulatory Expert, Harmony Healthcare International

Elisa Bovee has been working in the healthcare environment advocating for patients through education and clinical guidance. With a degree in Occupational Therapy she has managed a national operations team performing audits and analysis across the US for skilled nursing home providers.

Her expertise includes compliance programs, reimbursement and regulatory, development of education programs, skilled documentation for nursing and therapy and managing claims through the development request and denial phases.

Elisa has presented programs targeting all interdisciplinary groups throughout the country for audiences seeking guidance and clarity on a multitude of regulatory and clinical topics. Additionally, she has written and contributed to articles for national trade publications.

Topic Background:

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.

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