Medical records documentation is a vital aspect of the overall care that we provide to our residents. Skilled documentation will support the quality care that we provide. Incomplete, or inappropriate documentation may reduce reimbursement, precipitate survey deficiencies and may even result in substantial fines and penalties. This webinar will guide participants through the "do's and don'ts" of medical records documentation.
During this informative webinar, participants will:
- Examine the role of documentation as a tool to communicate assessment information to the entire treatment team.
- Explore how to develop individualized, resident centered Care Plans which are directly linked to the Resident Interview, MDS 3.0 and the CAA.
- Examine the role of documentation as a tool to communicate comprehensive plans of care to front line care providers.
- Identify potential survey "flags" which may lead to challenges during survey.
- Discuss what to and what not to document within care plans and progress notes.