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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

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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: 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.

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. What Is “Required”?

There are many real rules in home health, but there are also some that are not actually based on regulations. In order to create defensible documentation, clinicians need clarity around expectations. This chapter will explain the requirements surrounding both objective and assessment information.

2. What Is in the Toolbox?

A good mechanic needs more than one tool to complete the job, yet many clinicians include little or no objective information in their documentation to support skilled care and measure the impact over time. This chapter will examine objective measures that can be used by a variety of disciplines to expand the content of the toolbox.

3. Analyzing Findings

Collecting subjective information and reporting objective measurements are important components of defensible documentation but in and of themselves do not clearly support skilled care. It takes discipline-specific expertise to interpret findings and connect them to the need for intervention. This chapter will provide strategies for documenting clinical decision-making that takes skilled need to the next level.

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