Documentation

Also in the news for June 13, 2014 . . .

Senators ask for provider input on healthcare data availability ... "Frailty index" can help predict post-surgery SNF admission ... Hospice association sues CMS over documentation rule ... Complex nursing home embezzlement case can go to trial

Top 10 ways to avoid litigation

Top 10 ways to avoid litigation

In nursing home lawsuits, plaintiffs are often unhappy family members of residents who have experienced falls, pressure wounds, unexplained injuries or death. In our practice defending long-term care facilities, we have identified some relatively simple and straightforward actions that nursing homes can take to avoid litigation.

Ready, set ... Just kidding! (ICD-10 adventures continue)

Ready, set ... Just kidding! (ICD-10 adventures continue)

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Is that how everyone is feeling about the ICD-10 delays? Well, that's how I'm feeling. We almost got within the six-month window for implementation. Just when we were all geared up and ready to go, the government pushes the deadlines out again for one more year.

Ask the nursing expert ... about ICD-10's impact on nurses

Ask the nursing expert ... about ICD-10's impact on nurses

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What is ICD-10? What does this mean for nurses?

Defining tolerance in therapy

Defining tolerance in therapy

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How do you define tolerance? Is tolerance measurable? Is tolerance too subjective? What about activity tolerance? We love to document how patients are improving activity tolerance, but many times that's all we state in our documentation. So what have we said? Very little.

Jimmo guidance: Document goal before you provide care

Jimmo guidance: Document goal before you provide care

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Skilled nursing facilities should not claim that therapy was to maintain a patient's condition if documentation reflected only an improvement goal.

Asking for the medical record

Asking for the medical record

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Millions of dollars have been paid by nursing homes who unsuccessfully defended themselves against incomplete or absent documentation. There are not as many legal guidelines regarding medical records maintenance as you might think; however, there are essential legal aspects of charting to keep in mind.

Nursing home optometrist gets 33-month sentence for overbilling

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An optometrist who served Georgia nursing homes faces a 33-month prison sentence for defrauding Medicare.

Personal stories every therapist should know

Personal stories every therapist should know

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What's the point of all of our treatment interventions and plans of care if we can't relate to our patients? If you can put a face and personality behind your justification for therapy services, you'll be way ahead of the game.

Investigators find new ways to reduce turning schedule

Investigators find new ways to reduce turning schedule

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Nursing staff can turn residents less often if high-density foam mattresses and attentive documentation are being used for pressure ulcer prevention, research has found.

Ask the legal expert ... about antipsychotic medication liability

Ask the legal expert ... about antipsychotic medication liability

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I'm an administrator who's read all of this stuff about overuse of antipsychotics on long-term care residents. I like and trust my director of nursing, medical director and clinical staff — to a degree, that is — but what can I do to REALLY know that we're not overusing this stuff, and would not be liable for some sort of adverse regulatory or court findings?

Less frequent turning is needed with the right equipment and practices, pressure ulcer study finds

Less frequent turning is needed with the right equipment and practices, pressure ulcer study finds

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Nursing staff can turn residents less often if high-density foam mattresses and attentive documentation are being used for pressure ulcer prevention, according to a recent study.

GTB. AYS?

GTB. AYS?

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Can anyone guess what the title to this blog is stating? In the current culture of text messaging and abbreviations for everything, it can be a danger zone for medical documentation. Unfortunately, I have not made up this one.

Ask the care expert ... about photographing wounds

Ask the care expert ... about photographing wounds

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I am a charge nurse on a skilled unit. We do not take photos of wounds, but I would really like to take pictures. As they say a picture is worth a 1,000 words. Do you agree?

Ask the treatment expert ... about pressure ulcer documentation

Ask the treatment expert ... about pressure ulcer documentation

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How much do we have to document risk and implemented interventions to prevent pressure ulcer development?

Execute documentation as it's claimed: survey expert

Execute documentation as it's claimed: survey expert

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An industry expert served up straightforward advice during a recent McKnight's Super Tuesday webinar: Accurately claim what you do, and do what you claim.

Cracking the code

Cracking the code

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Long-term care administrators and nurses are under pressure to train staff to assess and document skin conditions to keep patients out of the hospital.

You're probably guilty of too much documentation

You're probably guilty of too much documentation

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Is it time for a diet? Not a food diet, but a documentation diet. I've written previous blogs about documentation quick tips, top 10 reasons for denials, and so on. But, how many of you are guilty of over-documentation? Is that even possible? Well, yes, it is.

How to document for rehabilitation work objectively

How to document for rehabilitation work objectively

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As the scrutiny continues to increase on rehabilitation documentation, finding ways to document objectively has become a major focus for just about everyone involved.

Upon further review

Upon further review

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Providers recoiling from recent uptick in therapy claim audits should expect even more scrutiny in the future as regulators look to increase surveillance.

The three C's are the key!

The three C's are the key!

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How do you justify the reason for rehab, length of stay and intensity of treatment? You turn to the 3 C's.

Just ask Petraeus

Just ask Petraeus

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Well, it wasn't easy to get there, but we have a new CIA director sworn in. With John Brennan taking over the spy agency, now's a good time to think back to what happened to his predecessor, General David Petraeus.

Leadership strategies for a changing healthcare world

Leadership strategies for a changing healthcare world

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Strong leadership is a vital ingredient to any successful organizational or system change. Increased consumer demands, strategic positioning and partnerships as well as an increased push towards community-based care are forcing post-acute leaders to serve as the catalyst for change.

Restorative nursing boosts resident care and billing levels, expert explains

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Activities of daily living and restorative nursing present good chances to optimize reimbursement, a nursing expert said Tuesday at the National Association of Directors of Nursing Administration/Long-Term Care conference in Nashville.

Therapists can co-treat? Why yes, they can!

Therapists can co-treat? Why yes, they can!

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Have you heard? Yes, it's true. We can now provide therapy co-treatment with another discipline WITHOUT splitting our treatment time. But, not so fast ...

'The therapy caps are back!!!'

'The therapy caps are back!!!'

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Are the therapy caps back? Well, sort of. Here's a quick summary of the current regulations that were recently passed and how they affect you.

Whatchamacallit

Whatchamacallit

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I'll bet that "regdiculous" and "disgustipating" would become a part of normal vocabulary at your workplace immediately.

More incentives to embrace technology

More incentives to embrace technology

Legislative and regulatory changes are forcing nursing home providers to seize opportunities to incorporate charting and care-plan technology into their facilities.

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