Our small little company probably sees more denials than anyone else other than say Palmetto or one of the Zone contractors. So we make a lot of fuss about documentation and getting paid but while we are very good about finding errors, we don’t offer as much as we should in teaching documentation with payment in mind. I’m not going to bother with that now as I have a lot to do so let me just show some examples of bad, better and really good documentation.
Skilled Teaching – Diet
Bad: taught low sodium diet. (worse if this is not the first time)
Better: Taught patient how to read food labels for sodium content. Used handout attached.
Best: Taught American Heart guidelines for low sodium diet according to handout pages 1 and 2. Copy attached and left in home folder.
Bad: SOB on exertion (everyone gets short winded if they exert themselves enough)
Better: Patient is short of breath when walking 20 feet.
Best: Patient is unable to leave the home due to SOB r/t CHF, arthritic pain and impaired judgment due to narcotic medications. Requires cumbersome assist devices and at least one person to help leave the home.
Diabetes Foot Check
Bad: Taught patient to perform foot care.
Better: Inspected all surfaces of feet. No problems noted. Patient was able to demonstrate foot care with a mirror.
Best: Inspected all surfaces of feet while simultaneously instructing patient on foot care and (proper footwear), (risks of decreased sensitivity), (risks of going without shoes), (when to see podiatrist), (importance of annual eye exam). Take your pick and rotate through the list.
Bad: PT/INR drawn per orders and brought to lab.
Better: PT/INR drawn per orders. Called team leader to watch for results.
Best: 10:00 PT/INR drawn. Dosage of 5 mg/day Coumadin noted on lab slip. 4:00 pm MD confirmed receipt of lab. INR 2.8. No new orders.
Any0ne else care to add to the list? Yes, you’ll chart a little more but if you blow off the recap of what is on the flow sheet – assessed all body systems, patient awake alert and oriented times 3, denies pain, etc., etc., you may find that you write less and say more. Better yet, you will get paid for your hard work and your outcomes will improve as well.