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.
Skilled nursing facilities should not claim that therapy was to maintain a patient's condition if documentation reflected only an improvement goal.
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.
An optometrist who served Georgia nursing homes faces a 33-month prison sentence for defrauding Medicare.
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.
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.
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?
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.
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.
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?
How much do we have to document risk and implemented interventions to prevent pressure ulcer development?
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.
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.
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.
As the scrutiny continues to increase on rehabilitation documentation, finding ways to document objectively has become a major focus for just about everyone involved.
Providers recoiling from recent uptick in therapy claim audits should expect even more scrutiny in the future as regulators look to increase surveillance.
How do you justify the reason for rehab, length of stay and intensity of treatment? You turn to the 3 C's.
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.
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.
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.
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 ...
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.
I'll bet that "regdiculous" and "disgustipating" would become a part of normal vocabulary at your workplace immediately.
Legislative and regulatory changes are forcing nursing home providers to seize opportunities to incorporate charting and care-plan technology into their facilities.