Achieving Defensibility in Clinical Documentation

Description

Session one of our Defensible Documentation Series

Achieving Defensibility in Clinical Documentation Summary

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

Defensible Documentation Key Points

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, and any inconsistencies should be addressed and clarified 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.”

Customer Feedback:

“Just listened to my little $7 purchase and it is great as I thought it would be. This is exactly what we are diving into this year so kudos on reading my mind. And kudos to Cindy for keeping it real.”

Roberta Mysels, CFO/Owner, ACE Home Health Care Services Inc

Want to get to Defensibility in all aspects of Documentation?  Check Out Our New Series Here