Fundamental Concepts of Defensible Documentation

Course overview

It is often said, "If it is not documented, it was not done." This cliché, while true, often triggers frustration in clinicians struggling to keep up with documentation. Poor documentation has many costs for SNF providers, including lost time and lost money. Poor documentation is a drain on the morale of nurses and therapists and is more likely to portray the wrong message about the value and quality of care delivered in a skilled nursing facility. Yet the challenge for many new to intermediate-level clinicians is that documentation standards and coverage criteria frequently change, making resident care even more complicated. This course will examine the technical and clinical criteria for skilled nursing facility coverage and the core principles of documentation. Armed with a fundamental understanding of this information, clinicians will be able to meet documentation expectations.