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Defensible Documentation in Home Health: Care Planning & Goal Setting

presented by Diana 'Dee' Kornetti and Cindy Krafft

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Financial: Dee Kornetti and Cindy Krafft are co-owners of the consulting business, Kornetti & Krafft Health Care Solutions. They receive compensation from MedBridge for this course.

Dee Kornetti is a chapter contributor to the  Handbook of Home Health Care Administration, 6th edition, and co-author of the book, The Post-Acute Care Guide to Maintenance Therapy, for which she receives compensation.

Cindy Krafft has written two books—The How-to Guide to Therapy Documentation and An Interdisciplinary Approach to Home Care and co-authored her third, The Post-Acute Care Guide to Maintenance Therapy, for which she receives compensation.

Nonfinancial: Dee Kornetti is the president of the Home Health Section of the APTA. Additionally, Dee Kornetti serves as the president of the Association of Homecare Coding and Compliance, and is a member of the Association of Home Care Coders Advisory Board and Panel of Experts.

Cindy Krafft has been involved at the senior leadership level of the Home Health Section of the American Physical Therapy Association. She has worked with CMS to clarify regulatory expectations and address proposed payment methodologies.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

MedBridge is committed to accessibility for all of our subscribers. If you are in need of a disability-related accommodation, please contact [email protected]. We will process requests for reasonable accommodation and will provide reasonable accommodations where appropriate, in a prompt and efficient manner.

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Video Runtime: 47 Minutes; Learning Assessment Time: 19 Minutes

The “P” portion of the SOAP note ("plan") is not a new concept when it comes to clinical documentation. Care planning is not just a task at a single point in time, but an evolving process over the course of care. Goal setting requires the balance between being measurable (quantifiable) and meaningful (patient focused). This course will examine strategies for creating individualized care plans with an interdisciplinary focus.

Meet Your Instructors

Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C

Diana 'Dee' Kornetti, a physical therapist for 30 years, is a past administrator and co-owner of a Medicare-certified home health agency. Dee now provides training and education to home health industry providers through a consulting business, Kornetti & Krafft Health Care Solutions. She serves as chief operations officer with her business partners Cindy Krafft and…

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Cindy Krafft, PT, MS, HCS-O

Cindy Krafft brings more than 20 years of home health expertise that ranges from direct patient care to operational and management issues. Years spent in the homes of patients confirmed that she was in the best setting to focus on functionality and the specific challenges faced by each patient. Cindy recognizes that providing care in…

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Chapters & Learning Objectives

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1. Individualized Care Planning

Electronic documentation tools have positive impacts on home health documentation, but the convenience of choosing from standardized lists has led to care plans that lack patient specifics. Surveyors have been citing agencies for this issue, as well as the lack of documentation that the care plan is being completed as written. This chapter will reframe the concepts of care planning by going back to fundamental requirements.

2. Measurable and Meaningful Goals

Creating goals is a golden opportunity to highlight the individualized focus of the plan of care. Selecting goals from standardized lists or choosing goals because they are "supposed to" be on the plan has negatively impacted the ability of goal statements to meet true compliance expectations. This chapter will examine a template that clinicians can use to evaluate how goals are being written and provide examples that reflect the concepts of measurable and meaningful.

3. Interdisciplinary Care Examples

Interdisciplinary care planning is more than sitting in a meeting and having clinicians report the focus of each individual service. Creating a common focus can make the documentation of care planning and, ultimately, care delivery better align with efforts to reduce rehospitalizations. This chapter will provide examples of interdisciplinary care for diagnoses commonly seen in home health.

More Courses in this Series

Defensible Documentation in Home Health: Fundamental Concepts

Presented by Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C and Cindy Krafft, PT, MS, HCS-O

Defensible Documentation in Home Health: Fundamental Concepts

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
Video Runtime: 45 Minutes; Learning Assessment Time: 19 Minutes

No one chooses to be a nurse or therapist based on a love of documentation, but the ability to effectively and efficiently communicate defensible content goes hand in hand with providing skilled care. Clinicians often lament the volume of documentation associated with working in home health and express frustration over the tools they are required to complete. This session will establish the foundation of defensible documentation and provide an overview of a framework supporting the ability to make documentation smarter, not harder.

View full course details

Defensible Documentation in Home Health: Patient-Centered Care

Presented by Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C and Cindy Krafft, PT, MS, HCS-O

Defensible Documentation in Home Health: Patient-Centered Care

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
Video Runtime: 28 Minutes; Learning Assessment Time: 19 Minutes

The “S” portion of the SOAP note ("subjective") is not a new concept when it comes to clinical documentation. With recent revisions to the Home Health Conditions of Participation, there is a renewed focus on the ability to speak to the patient experience and individualized care planning. This course will examine strategies for collecting subjective information and incorporating it into defensible documentation.

View full course details

Defensible Documentation in Home Health: Quantifiable Information

Presented by Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C and Cindy Krafft, PT, MS, HCS-O

Defensible Documentation in Home Health: Quantifiable Information

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
Video Runtime: 37 Minutes; Learning Assessment Time: 19 Minutes

The “O” portion of the SOAP note ("objective") is not a new concept when it comes to clinical documentation. Although the focus seems to be more on therapy than on nursing, all clinical documentation needs to contain a level of quantifiable information by which patient improvement or stabilization can be measured. The “A” portion ("assessment") goes hand in hand with the “O” as it is insufficient to just provide measures without analyzing the findings. This course will examine strategies for collecting and analyzing objective information and incorporating it into defensible documentation.

View full course details

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