Nursing And Therapy Documentation In Long Term Care

"This resource will help you: Align with MDS 3.0 documentation requirements. Coordinate documentation between nurses and therapists to improve resident care. Gain the perspective of nursing or therapy to appreciate their specific approach to skilled services. Reduce your audit risk and strengthen reimbursement claims with comprehensive documentation. Prove medical necessity and need for skilled care by practicing accurate documentation"--Page 4 of cover

Description:An important aspect of patient care as an occupational therapist in a skilled nursing/long-term care (SNF/LTC) facility is completing thorough documentation of services provided. Completion of documentation in this setting can be overwhelming and time consuming but it doesn't have to be. Documentation for Skilled Nursing & Long-Term Care: A Guide for Occupational Therapists presents an overview of standard documentation in this setting from initial evaluation to the discharge of OT services. This book will discuss the necessary components for quality documentation of OT services including:?Initial OT evaluation and establishment of OT plan of care?Functional and measurable goals?Section GG of Minimum Data Set (MDS)?Daily treatment notes and billing ?Weekly progress notes, 10th visit notes, insurance updates?Updated OT plan of care/recertification?Discharge Summary?Group, concurrent and co-treatments?Point of service documentation and productivity?OT screens Documentation for Skilled Nursing & Long-Term Care: A Guide for Occupational Therapists is intended to educate the following:?An OT student starting Level II fieldwork in a SNF/LTC facility?A new graduate OT entering employment in a SNF/LTC facility?An experienced OT transitioning to SNF/LTC from a school based or mental health setting?An OT working in SNF/LTC who strives to improve their clinical documentation skillsThis book is meant to be a resource to guide clinical documentation. After reading this book, you will be more confident in documenting the OT services you provide from the start of care to the discharge of OT services.

This manual offers a quality documentation system using nursing diagnosis developed specifically for long-term care. it provides practical quality tools to guide professional nurses and interdisciplinary staff members in meeting documentation requirements under OBRA '87.

Among the issues confronting America is long-term care for frail, older persons and others with chronic conditions and functional limitations that limit their ability to care for themselves. Improving the Quality of Long-Term Care takes a comprehensive look at the quality of care and quality of life in long-term care, including nursing homes, home health agencies, residential care facilities, family members and a variety of others. This book describes the current state of long-term care, identifying problem areas and offering recommendations for federal and state policymakers. Who uses long-term care? How have the characteristics of this population changed over time? What paths do people follow in long term care? The committee provides the latest information on these and other key questions. This book explores strengths and limitations of available data and research literature especially for settings other than nursing homes, on methods to measure, oversee, and improve the quality of long-term care. The committee makes recommendations on setting and enforcing standards of care, strengthening the caregiving workforce, reimbursement issues, and expanding the knowledge base to guide organizational and individual caregivers in improving the quality of care.

Thoroughly updated for its Second Edition, this comprehensive reference provides clear, practical guidelines on documenting patient care in all nursing practice settings, the leading clinical specialties, and current documentation systems. This edition features greatly expanded coverage of computerized charting and electronic medical records (EMRs), complete guidelines for documenting JCAHO safety goals, and new information on charting pain management. Hundreds of filled-in sample forms show specific content and wording. Icons highlight tips and timesavers, critical case law and legal safeguards, and advice for special situations. Appendices include NANDA taxonomy, JCAHO documentation standards, and documenting outcomes and interventions for key nursing diagnoses.

Clinical documentation can significantly affect a nursing home's survey results, reimbursement received, and most importantly, resident care. Yet, little formal training is given on how to complete this complicated, and often confusing, process. With so much at stake, it's critical that nurses have a resource they can turn to in order to help achieve accurate, comprehensive documentation for all residents.

Elder Care in Occupational Therapy has been extensively revised into a new and completely updated second edition. This pragmatic text presents up-to-date information in a user-friendly format that seamlessly flows from one subject to the next. From wellness to hospice, Elder Care in Occupational Therapy, Second Edition offers a broad yet detailed discussion of occupational therapy practice that is devoted to older adults. A wide variety of topics are covered in a concise format, such as historical perspectives, theoretical insights, the aging process, and current interventional strategies, to name a few. Twenty informative appendices are also included that clarify issues such as Medicare coverage, community and clinical living arrangements, client-centered practice, exercise programs, evidence-based practice, and a summary of the newly adopted Occupational Therapy Practice Framework: Domain and Process. Additional features: Contains information about the most advanced scientific achievements that can ultimately affect occupational therapy. Lists new and updated resource materials. Presents case studies that provide theoretical considerations and Intervention methods. Clearly discusses exciting and new venues for occupational therapy programming. Explains fundamentals of documentation and current reimbursement issues. Perfect for the student or clinician, Elder Care in Occupational Therapy, Second Edition provides classic, professional information on theory, disease entities, and intervention in a comprehensive format.