Bringing Back the SOAP Note: Practical Strategies for Defensible Home Health Documentation – 4 Part Series

Description

Many home health veterans and tool developers have the battle scars of trying to change documentation tools as there never seems to be one that fixes the problems completely let alone makes everyone happy. The focus has been on the end product of content and attempts to find fixes that actually decrease clinical decision making by relying heavily on check boxes or drop down choices.

This series of webinars will create a change in how clinicians think about documentation by peeling back layers of myth and unclear directions and getting back to the very foundational components of good content creation – subjective information, objective data, assessment of patient response and performance and planning for ongoing care. The necessary level of content is driven by the clinician having the right focus and not a new form.

4-Part Webinar Series: 

Newly Updated!  Great Addition to your Orientation and Training Library

The ability to create defensible documentation that clearly and concisely supports medical necessity continues to challenge all disciplines providing care in home health. Although specific attention keeps therapy services in the cross hairs for denials, audit efforts clearly indicate that the deficits being used to deny payment are seen just as often in nursing notes as well. Many clinicians are quick to lay a degree of blame on the documentation tools they are given to use. Both paper and electronic options are far too often held more accountable than the person completing the form and actually responsible for the content.
Many home health veterans and tool developers have the battle scars of trying to change documentation tools as there never seems to be one that fixes the problems completely let alone makes everyone happy. The focus has been on the end product of content and attempts to find fixes that actually decrease clinical decision making by relying heavily on check boxes or drop down choices.
This series of webinars will create a change in how clinicians think about documentation by peeling back layers of myth and unclear directions and getting back to the very foundational components of good content creation – subjective information, objective data, assessment of patient response and performance and planning for ongoing care. The necessary level of content is driven by the clinician having the right focus and not a new form.

Series Objectives:

•Define and apply the terms skilled, reasonable and necessary in the context of clinical documentation.

•Identify two strategies for collecting both subjective and objective information.

•Integrate “professional opinion” into initial assessments and routine visits to support clinical decision making.

•Formulate goals that meet the expectations of measureable and meaningful.

Webinar 1: Subjective – Click Here to Access Subjective Podcast 

Overview:
Review of records leaves some wondering “what happened to subjective information?” Notes appear to have no feedback or contribution from the patient and caregiver as to current status, prior status or impact of care already delivered. The ability to effectively gather meaningful subjective information is a skill that must be learned and cultivated especially in home based care when so many hours within a 60 day episode do not have skilled clinicians directly accessing the patient.

This session will teach specific strategies for active patient interview and guidelines for the information that should be collected specifically on initial visits as well as on every visit provided to the patient regardless of discipline.

Session 1 Objectives:
1. Discuss key focus areas of subjective information

2. Examine interview strategies that use open ended questions to gather critical pieces of information.

3. Connect specific subjective information to content areas of routine documentation to increase support for medical necessity

Webinar 2:  Objective Data – Click Here to Access Objective Podcast

Overview:
There has been significant discussion coming from external reviewers regarding the need for objective information to be present in clinical documentation. Skilled care changes lives and that change has to be measured or quantified in a meaningful way.
Vital signs, pain levels and the Timed Up and Go are now being documented with regularity but lacks two critical components – evidence of interpretation of these findings by a skilled professional and connection to care planning going forward.
This session will examine key areas of quantifiable information for all disciplines and take it further by incorporating interpretation of results and making the connection to care delivery clear and concise.

Session 2 Objectives:
1. Discuss core quantifiable information that should be considered on initial assessments and routine visits.

2. Examine how objective data can and should be interpreted

3. Incorporate specific data elements into developing and advancing a plan of care.

Webinar 3:  Assessment – Click Here to Access Assessment Podcast
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Overview:
The assessment component of documentation is one of the most overlooked opportunities to support the need for skilled care. With increasing clinical experience comes the risk of losing sight of the complexity of care being provided each day. What is done on instinct by the nurse or therapist is often rocket science to the people we serve. Assessment is an chance to show why it takes skilled professionals to be involved in the care of this specific patient.

This session will tackle the focus specifically on assessment opportunities on every single visit and provide strategies for strategic documentation that highlights skilled care.

Session 3 Objectives:
1. Define assessment in the hands of RNs, PTs, OTs and SLPs and in the hands of LPNs, PTAs and OTAs.

2. Discuss the focus of assessment and the connection to both subjective and objective information

3. Examine documentation strategies to create meaningful assessment content without a risk of repetition.

Webinar 4: Plan and Goals 

Overview:
Regulation mandates a plan of care that tends to be developed at the beginning of an episode but it is a challenge to find clear documentation supporting ongoing use of this plan on every visit. Review of records often reveals the area of “plan for next visit” left blank or only contain statements such as “continue per plan of care” with no additional detail. Utilizing the concepts of active care planning confirm that skilled professionals are managing this specific patient and making evidence based decisions about what should happen over the course of an episode.

This session will move care planning from a stagnant to a dynamic process that impacts every visit provided and generates content that has relevance and meaning.

Session 4 Objectives:

1. Define planning care from the beginning and throughout an episode of care.

2. Discuss the connection between subjective information, objective data, assessment and care planning.

3. Examine specific documentation opportunities to confirm and update an active care plan.

All handouts are attached and available at checkout