Achieving Defensibility in Clinical Documentation

Empowering Healthcare Providers

Summary – Excerpted from Session One of the product below

Cindy Krafft discusses the importance of understanding defensibility in clinical documentation to ensure appropriate payment for services. She encourages healthcare providers to view documentation defensibility as an opportunity to showcase their expertise rather than a burden.

Key Points from Achieving Defensibility in Clinical Documentation

1. The face-to-face requirement was implemented to address vague orders and ensure greater physician involvement in patient care.
2. The primary reason for home care must accurately reflect the patient’s condition. Address and clarify any inconsistencies with the referring physician.
3. Continuous communication and coordination with physicians are necessary to obtain updated face-to-face documentation when needed.
4. Home-bound status is a top reason for denial in home health care, and current documentation practices lack specificity.
5. Healthcare professionals play a vital role in home health care and need to take ownership of their expertise and the documentation process.
6. Diagnosis does not automatically guarantee coverage or financial compensation.
7. Empowerment and a positive mindset can transform the perception of documentation.

Things to Remember- Cindy Krafft quotes:

• “We are dealing in a situation where the person who’s writing the check has never met you, has never met the patient.”

• “Defensibility has made us feel like we’re in a foxhole, fighting off an enemy. But when you look at words that mean the same thing as defensibility, they’re not dependent words. They’re empowering words.”

• “We need to document how I modify my teaching based on the cognitive situation of the patient skill.”

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