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If you didn’t document it, it didn’t happen. Today, I would like for us all to consider not merely the importance of documenting daily skilledcare but also the reason for referral and the need for initiating services in the first place. How many times have we all heard those words?
As you read below, I also want you to consider: Does the care you provide daily evidence complexity in the interventions you use and the documentation you complete. CERTIFICATION is the physician’s/non-physician practitioner’s (NPP) approval of the plan of care. How does this impact skill? Now on to complexities.
Therefore, evaluation, re-evaluation and assessment documented in the Progress Report should describe objective measurements which, when compared, show improvements in function, decrease in severity or rationalization for an optimistic outlook to justify continued treatment. She can be reached at rkinder@broadriverrehab.com.
Health care providers are giving really good patient-focused care, but we’re not doing what I like to call family-centered care. There’s not even a place in most medical records to document that. It is skilledcare even when you have no skills, and you have no license, but you’re doing this 24 hours.
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