The Compliance Minute
Recently, I’ve been involved in conversations and investigations related to documentation within our company. Because of that, I thought it would be a great article for this month’s installment of “The Compliance Minute”.
Many of us have heard the old adage, “if it wasn’t documented, it wasn’t done”, or something similar. While this phrase gets over-utilized in my opinion, it’s quite true and accurate. Accurate, and thorough documentation is important for many reasons. In order for Mission Point to “Deliver Excellence. Every Life. Every Moment. Every Day.”, we need to document. This ensures the continual quality of care and services needed for each resident. Failing to document, or failing to document accurately and thoroughly can place the residents health and safety at risk. This can lead to negative outcomes for both the resident, the facility, and the licensed health professionals tasked with caring for that resident.
In addition, documentation matters for reimbursement purposes. Mission Point, just like other nursing homes in the long-term care industry seek to be reimbursed from government health programs for the care and services provided. Both Medicare and Medicaid have stringent documentation expectations that skilled nursing facilities must meet in order to receive reimbursement.
Finally, documentation ensures that we are able to show our stakeholders (the residents, family members, survey agencies, etc.) the quality care we provide each day. Documentation tells the story of the residents stay with us, the care they received, and the outcomes from that care.
Some helpful tips when it comes to documenting:
- Be clear, concise, accurate, and thorough.
- Limit the use of abbreviations and use only those that are company-approved.
- When correcting, making a change, or entering a late entry note – be sure to document the reason, who is making the correction, and the date of the correction. A single strikethrough for errors will be made.
- Deleting documentation is greatly discouraged and should not be used.
- Document only what you witnessed or assessed. Do not make assumptions.
- The use of “cut and paste” is also strongly discouraged and should not be used.
For more information regarding Mission Point expectations on documentation, please reach out to your regional director, Angela Barnes, Health Information Director, or Vice President of Clinical Operations Kelly Dines.
Emery Dumas, LNHA, CDP, CHC
MPHS Corporate Compliance Officer