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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

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Disclosure Statement:

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: 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.

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. “Patient Focused”

How much more of a “patient-focused” setting can there be than home health? Yet clinicians often miss opportunities to speak to specifics in their documentation. This is not just a suggestion as it is required in the Conditions of Participation. Repeated checking of boxes on a form will not meet these expectations. This chapter will outline how the Conditions of Participation address the need to be patient focused, and will provide strategies for compliance.

2. ICF in Home Health

Creating documentation that is patient focused is not about making a better checklist within each note but about seeing the big picture when approaching each encounter. The International Classification of Functioning, Disability and Health (ICF) model can provide a framework to assist clinicians in documenting patient-focused concepts. This chapter will provide an overview of the ICF model and its applicability in the home health setting.

3. Getting Back to Basics: Subjective Information

Use of the SOAP note in its traditional form may not be clearly seen in many of the home health documentation tools, but the principles remain. With all of the other requirements that must be met on every note, subjective details can be overlooked. This chapter will examine strategies for collecting and documenting meaningful subjective information.

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