Patient-Centered Defensible Documentation

1. The Why of Patient-Centered Care

Patient-centered care is care that is specific to the resident and not generalized or generic. Discovering the patient’s preferences and wishes is one method of strengthening documentation. This chapter will provide real-life examples of how the concept can be translated into practice and become a natural part of the documentation.

2. Using the ICF to Support Documentation

The International Classification of Functioning, Disability and Health (ICF) is a unified, standard language and framework that captures how people with health conditions function in their daily lives rather than focusing on their diagnoses. That framework fits with what SNF providers work to do every day: focus on residents' abilities rather than only on their disabilities. This chapter will provide an overview of the ICF and give examples of how the framework can support nursing and therapy documentation.

3. The Value of Patient Engagement

Patient engagement is increasingly recognized as a critical component of patient-centered care. This chapter defines the concept and explains why it is critical to both patient-centered care and documentation. Examples of patient engagement strategies and opportunities will be shared, as well as how those strategies are directly connected to documentation. Factors that positively and negatively influence patient engagement will also be discussed, as they can significantly alter a patient’s care outcome.