Documentation: Make it Fast, Make it Functional

Course overview

Documenting functional progress for both part A and B Medicare services. Analyze data to update plan of care, set functional and realistic goals, document treatment effectively and update progress to maximize reimbursement. Create clinical documentation that demonstrates reasonable and necessary care that is skilled and valuable. Identify relevant subjective, objective and assessment data. Formulate entirety of plan of care from evaluation to discharge. Practical assessment and re-assessment strategies for functional deficits, underlying conditions and co- morbidities. Select appropriate data to formulate SMART goals. Determine appropriate interventions based upon data and assessments. Accurately update and document plans of care, functional and realistic goals, treatment and discharge summaries to maximize reimbursement. Describe patient deficits in terms of current disability models and document "skilled interventions" by payer source. Justify current plan of care and future skilled interventions at mandated intervals. Implement clinical documentation that demonstrates skill, medical necessity, and value.