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Megan Ussery joins the podcast for part 2 of her 2 part Skilled vs. Unskilled series. In this week’s episode she focuses on skilled documentation to support skilled services (check out Episode 81 for a review of skilled services). She offers a few simple strategies to enhance your documentation and support the skilled services provided:
1. Document point of service or right after a service is provided
2. Document services which address the primary reason for SNF and primary medical diagnosis
3. Document patient response to services and interactions with other health care professionals
4. Don’t document unskilled, repetitive, redundant information. Instead, say more with less words
