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Interprofessional Collaboration in Defensible Documentation

presented by Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-MTA and Ellen R. Strunk, PT, MS, GCS, ACEEAA, CHC, RAC-CT

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Disclosure Statement:

Financial: Ellen R. Strunk and Maureen McCarthy receive compensation from MedBridge for this course. There is no financial interest beyond the production of this course.

Nonfinancial: Ellen R. Strunk and Maureen McCarthy have no competing nonfinancial interests or relationships with regard to the content presented in this course.

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: 35 Minutes; Learning Assessment Time: 23 Minutes

Skilled nursing facilities are required to develop a care plan for each beneficiary and provide services in accordance with the care plan. Several studies and investigations have found that SNFs had deficiencies in doing just that, resulting in inadequate care to those residents. This course will describe the purpose for and principles of care planning. Entry-level and intermediate-level clinicians will be able to describe how care plans ensure the team is working in tandem toward the patient’s goals. The course will provide examples of how incorporating resident-centered goals requires interprofessional collaboration and how successful interprofessional collaboration requires a shared, patient-centered vision.

Meet Your Instructors

Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-MTA

Maureen is the president of Celtic Consulting, LLC, a clinical reimbursement, clinical operations, and compliance advisory firm. She is also the CEO of MDSRescue, an organization that provides temporary MDS completion services across the country. Recognized as an industry leader in clinical reimbursement for long-term care, Maureen has been a registered nurse for more than…

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Ellen R. Strunk, PT, MS, GCS, ACEEAA, CHC, RAC-CT

Ellen R. Strunk, PT, MS, GCS, CEEAA, CHC, RAC-CT, has worked in various roles and settings as both a clinician and a manager/director. Ellen is an expert at helping customers understand the CMS prospective payment systems in the skilled nursing facility and home health settings, as well as outpatient therapy billing for all provider types.…

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Chapters & Learning Objectives

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1. Purpose of Care Planning

This chapter will present the key concepts of care planning and the differences between the baseline care plan, the therapy plan of care, and the comprehensive interprofessional/interdisciplinary care plan. An overview of the federal requirements will be included. This information is important for SNF nurses and therapists to understand in order to ensure compliance with state and federal requirements of participation.

2. Creating Goals That Address Resident Goals

Goals for therapy and nursing should help to drive the plan of care to the destination the resident desires. This chapter will provide practical strategies for ensuring the resident’s goals are reflected adequately in the care plan and in specific enough terms to ensure the care team is on the same page and delivering effective care.

3. Interdisciplinary Management of the Care Plan

Today’s residents have complex health needs and typically require more than one discipline to address their health issues, but that doesn’t mean we work alone. This chapter will tackle the real-life conundrum facing all therapists and nurses in the SNF setting—how can we achieve truly collaborative care?—and provide learners with examples and resources to assist them in their journey to achieve an interprofessional team.

More Courses in this Series

Fundamental Concepts of Defensible Documentation

Presented by Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-MTA and Ellen R. Strunk, PT, MS, GCS, ACEEAA, CHC, RAC-CT

Fundamental Concepts of Defensible Documentation

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: 24 Minutes

It is often said, “If it is not documented, it was not done.” This cliché, while true, often triggers frustration in clinicians struggling to keep up with documentation. Poor documentation has many costs for SNF providers, including lost time and lost money. Poor documentation is a drain on the morale of nurses and therapists and is more likely to portray the wrong message about the value and quality of care delivered in a skilled nursing facility. Yet the challenge for many new to intermediate-level clinicians is that documentation standards and coverage criteria frequently change, making resident care even more complicated. This course will examine the technical and clinical criteria for skilled nursing facility coverage and the core principles of documentation. Armed with a fundamental understanding of this information, clinicians will be able to meet documentation expectations.

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Patient-Centered Defensible Documentation

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Patient-Centered Defensible Documentation

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
Video Runtime: 41 Minutes; Learning Assessment Time: 25 Minutes

Recent revisions to the SNF requirements of participation (RoP) emphasize resident-centered care planning. But translating this concept into daily practice is still a challenge. This course will examine the concept of resident-centered care and how documentation is related to it. An introduction to the International Classification of Functioning, Disability and Health (ICF) will give clinicians a context in which they can apply new approaches. Strategies will be shared to help new and intermediate-level therapists and nurses demonstrate patient engagement within the documentation.

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Why Quantifiable Information Matters in Defensible Documentation

Presented by Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-MTA and Ellen R. Strunk, PT, MS, GCS, ACEEAA, CHC, RAC-CT

Why Quantifiable Information Matters in Defensible Documentation

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
Video Runtime: 42 Minutes; Learning Assessment Time: 20 Minutes

The implementation of the Patient-Driven Payment Model (PDPM) presents a new landscape for SNF documentation requirements. Clinicians have a lot to learn about what is expected by payers and reviewers alike. Defensible documentation doesn’t always mean more documentation. It means documenting more effectively. This course will discuss key components of documentation for the entry- and intermediate-level nurse and therapist, including key components of a comprehensive assessment, the importance of gathering objective information initially and throughout the episode of care, and the impact of the Minimum Data Set.

View full course details

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