After this course, readers will be able to:
- Identify methods for writing functional, measurable and realistic short-term objectives and long-term goals for restorative and maintenance-based levels of care
- Describe how to document levels of care within daily notes
- Describe best practices for documenting functional gains made during SLP services in progress reports
Introduction and Overview
This is Part Two of a two-part series on documentation in skilled nursing facilities. For everyone that was able to participate in Part 1, welcome back. To anyone that is new on today's call, we will be talking about some of the areas from Part 1 to give you a foundation. We talked about evaluation of plan of care requirements in Part 1; however, Part 2 will focus more on progress reports, goal writing, and discharge summaries.
This course will describe best practices for documenting skilled levels of care provided by an SLP, including an in-depth review of goal creation, daily note documentation, and progress report writing. In addition, case studies will be used in order to support documentation in your real world settings, to bring everything back to the real world.
We would like for participants to be able to identify methods for writing functional, measurable, and realistic short-term objectives and long-term goals for restorative (meaning rehab) and maintenance-based levels of care. Participants should be able to describe how to document skilled levels of care within daily note documentation. Participants will be able to describe best practices for documenting functional gains made during SLP services within progress reports.
There are two supplemental handouts that were included with the course materials. We will go through the dysphagia goals during this course, but the other handouts are a supplement for your toolkit.
Know Your Regulations
We will start with a general overview of some of the areas discussed in Part 1. The purpose of this course is to provide some guidance on documenting skilled level of care within skilled nursing facilities (SNFs), and it is likely you are treating Medicare patients. There are some key foundational regulations that you need to be in tune with. These include the Medicare Benefit Policy Manual Chapter 15, Sections 220 and 230; the National Coverage Determinations, which are regulations at the national level; and then the Local Coverage Determinations. Local Coverage Determinations are regionally specific regulations, so these will differ depending on your geographic location. They have guidance for CPT coding, ICD coding, as well as the essential areas for documentation. It is very important to know about these, if you are treating in a skilled nursing facility and you do not know who your Medicare Administrative Contractor (MAC) is, and what the Local Coverage Determinations are for your site. We will go over the four general criteria for reasonable and necessary skilled care that can be found in the Medicare Benefit Policy Manual.
