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Quality Auditing Tool
Policy Manual, K&K Maintenance Book
Few words spoken to clinicians cause more frustration than “documentation” as no one chooses to enter a medical profession in hopes of spending hours per day writing things down. The current level of scrutiny provides little room for leniency when it comes to consistent generation of defensible content. The challenge is to engage clinicians in the process to ultimately generate the level of detail required as efficiently as possible while still assuring an audit-proof level of medical necessity.
This session will connect the critical clinical concepts of interdisciplinary care planning to key elements of documentation. Examples are intended to move clinicians beyond “if you didn't document it you didn't do it” and explore the impact of nursing management and evaluation and maintenance therapy on content expectations.
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