All of us as health care professionals have been taught to document and if we do not document then perhaps we did not do it! Our chart notes have been valuable for a variety of reasons but with PDPM around the corner, it is time to look again at the quality of our documentation and make sure it supports what you are doing, and what you are communicating to payers and others. Our documentation likely needs to be improved in order to be as accurate, comprehensive, precise, and on time as possible. Ensuring this level of documentation will require communication with and support from all professionals, including physicians. Until they are familiar with the new expectations placed on them by PDPM they may need to be reminded of the need for contemporaneous documentation to support the MDS required assessments such as Function GG, cognitive, mood, and delirium assessments and the ICD-10 Coding for the Primary and Secondary diagnoses.
“Starting October 1, 2019, providers will have a single opportunity to set themselves up for financial success with a patient’s initial assessment.”
A. Spanko, Skilled Nursing News, 9.25.2018
That “single opportunity” is found in the 5-Day Admission MDS and all disciplines must contribute.