Nursing and Therapy Documentation in Long-Term Care

A team approach to MDS 3.0 skilled services documentation

Align resident documentation across multiple disciplines to improve quality of care as well as protect your organization from an audit. Proper documentation has never been more crucial under MDS 3.0, and this is the only product on the market that blends the perspectives of both a nurse and a therapist to ensure resident-centered care. Complete with downloadable tools and examples of documentation scenarios, you will create an interdisciplinary team approach to your documentation processes.

With this book you will be able to:

• Align with MDS 3.0 documentation requirements
• Coordinate documentation between nurses and therapists to improve resident care
• Gain insight into nursing and therapy skilled services to promote better collaboration
• Reduce your audit risk and strengthen reimbursement claims with comprehensive documentation
• Prove medical necessity and need for skilled care by practicing accurate documentation

Table of Contents

• Section 1: Introduction to Documentation and Long-Term Care
• Documentation
• Why do we document
• Definition of documentation
• Who governs documentation
• The C’s of documentation
• Importance of Collaboration with Different Disciplines
• MDS 3.0 Specific Item Overlap
  • Section G
  • Section P
  • Section I
  • Section J
• Benefits of Collaboration
  • Optimize care and patient outcome
  • Improve reimbursement
  • Achieve survey success
  • Create a positive working environment
• Section 2: Therapy
• Define key components of medical necessity
• Defensible documentation strategies
• Sample forms
• Considerations for MDS 3.0 documentation
  • Documentation to support individual, concurrent, and group therapy sessions
  • Supporting the RUG level billed
• Documentation by discipline
  • Physical therapy
  • Occupational therapy
  • Speech-language pathology
• Pitfalls to avoid
• Section 3: Nursing
• Documenting to support the services of skilled therapy
  • Skilled terminology
  • Daily documentation when therapy is the only skilling service
• Documentation to support the MDS 3.0 and Therapy
  • Section G
  • Section P
  • Scoring the MDS when contradictions exist in the medical record
• Documentation Dos and Don’ts
• Section 4: Restorative Nursing and Skilled Therapy
• Defining Restorative Nursing per the MDS 3.0
• Beginning the Process from Day of Admission
• Transition Skills from Therapy to Nursing
• Maintenance Programs versus Restorative Nursing
• Impact on Reimbursement
• Restorative Nursing as a Medicare Daily Skilled Service
• Section 5: Conclusion
• Strategies to improve collaboration
  • Conducting the Medicare meeting
  • Developing communication strategies

Audience

Director of rehab, therapy director, physical therapist, occupational therapist, speech therapist, administrator, DON/CNO, MDS coordinator, RN.

About the Authors

Kate Brewer, PT, MBA, GCS, RAC-CT president/owner, Progressive Rehab Solutions/ vice president, rehabilitation services for Greenfield Rehabilitation Agency, Inc. Brewer provides practical consulting services to rehabilitation professionals. She has presented nationally on documentation, coding, and rehabilitation management issues and is a recognized expert in long-term care rehabilitation.

Theresa A. Lang, R.N. BSN, RAC-C, WCC, vice president, Clinical Consulting, Specialized Medical Service (Milwaukee, WI). Lang has worked in long term care for more than 30 years. She has a broad range of experience including Medicare coverage and documentation, MDS Coding, sub-acute program development, and managed care contracting and pricing. Prior to her current role, she was a DON for a 227 bed sub-acute care facility.

• Books

• Other Long-Term Care Products
• Other Rehab Products