The Why of Documentation
What is the "thread" that connects every service component?
Documentation!
Do staff need to sign their documentation?
Yes - staff must electronically sign their documentation to be considered a billable service
Fill in the blanks - if it's not documented, it _____ ___________
Didn't happen
What are the other 2 pieces of the client's record besides daily service documentation that 1) give the diagnoses and symptoms and 2) provide the goals and objectives for clients to work on?
1) MHE or assessment
2) Treatment plan
If a client is with staff for 3 hours at their home, then goes to the store by themself for 2 hours, and then comes back to their home where staff are present for another 3 hours, how much total service time is billable that shift?
6 hours
How long do you have to document according to HHS?
According to VF?
48 hours
7 days but everything due by 3rd day of the month so billing can go out
Name at least 2 reasons why it is important to document services provided to clients
To prove medical necessity
To be able to bill for services
To communicate with others as to what happened that shift
Anything else relevant
If medications are passed during service delivery, what needs to be included in the shift note?
See MAR; any goals worked on related to a medication goal
What are at least 2 reasons why it's important to do documentation shortly after services are provided
Notes get less accurate as time goes by
Delays put revenue at risk (which means less pay for us all)
The next shift doesn't know what happened/lack of good communication
Why do we want staff to work on more than just a medication goal with clients?
Because treatment plans detail out many areas of need for clients, we want to be able to teach/model skills they need to achieve to support greater independence in living for them. The goal is to empower clients to do as much as possible for themselves!
List at least 5 elements required to be included in documentation
Client name, date of service, time service began/end, specific services provided that justify medical necessity, MAR, milage logs, supplies dispensed, staff name and credentials, electronic signature of staff
Give me 1 fact about documentation that has not already been covered in this game.
:)