Long-Term Care Survey Alert

The feds provide this cheat sheet for what to include in documentation for skilled nursing and therapy services:

• The history and physical exam pertinent to the patient’s care, (including the response or changes in behavior to previously administered skilled services);
• The skilled services provided;
• The patient’s response to the skilled services provided during the current visit;
• The plan for future care based on the rationale of prior results;
• A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences;
• The complexity of the service to be performed;
• Any other pertinent characteristics of the beneficiary.