Documentation

Clinical care is recorded in the medical record. This is the only evidence to demonstrate and record the work of the care team.

WHY

Clinical documentation forms the backbone of all quality measures, clinical and fiscal. All billing starts from clinical documentation of patient care. Documentation must always be timely, efficient, accurate, reliable and thorough.

WHO

Every agency, every staff person.

WHEN

Every day, every visit.

TO DO

Ensure all front line caregivers understand how to document, have access to the appropriate tools (forms, computers, internet connection, etc.), establish auditing procedures to support staff and for success.

RISK

Documentation falures leave patient care at risk for gaps and inconsistencies. It leaves the organization at risk for fiscal auditing and compliance audits.
 

RESOURCES

ElevatingHOME-Developed Resources
OASIS-C1, Coding , and the New Recalibrations: What This Can Mean for Your Agency (Webinar Archive)
ICD-10 Coding, Part 1: Overview and Planning (Webinar Archive)
ICD-10 Coding, Part 2: Drilling Down to the Details (Webinar Archive)
ICD-10 Coding, Part 3: Checklists for Success (Webinar Archive)
Public Resources
Outcome and Assessment Information Set (CMS)
ICD-10 (CMS)
Partner Resources
The Complete ICD-10 Guide (Axxess)
Other Resources (may involve a fee to access)
 
   

Other Topics

Policy

Quality

Direct Care

Financial