Away with S-O-A-P and on to Proficient Documentation

This text base course is a transcript of a live seminar titled "Away with S-O-A-P an On to Proficient Documentation” presented by Mary Daulong.   It is strongly recommended that you follow along with the course handout to ensure understanding of the course material.   >> Mary Daulong:  I will be referring to some materials that we talked about in detail in previous courses. Why Do We Document?I know this happens to all of us.  We see a lot of patients, and sometimes we have a little brain dead period.  That is one reason that we document.  We want to make certain that we can recall those things that are important for patient continuity.  We also have fear, so we document to mitigate professional liability.  In this particular cartoon, (Figure 1) the therapist is saying, “What is your lawyer’s diagnosis?”  Sometimes it is us against them because we have not documented appropriately.  Figure 1 – Slide 4We do not want to look inept.  These are actual notes from a hospital setting.  (Figure 2) I am not picking on hospitals; this just happens to be something that I found.  Some of the things that we write are just incredible.  Look at this one.  “The patient has chest pain if she lies on her left side for over a year.”  Sometimes we do not look at what we write, and what we say really does not make sense.  “On the second day, the knee was better, and on the third day, it disappeared.”  Of course the practitioner is probably talking about pain here, but we have to look at the way things appear in the document.  I know that I have had experiences testifying using notes of other therapists and it can be embarrassing when these types of notes do come up especially when they are presented by the attorneys.  Figure 2 – Slide 5The actual reason that we document is to make sure that we have optimal continuity.  So whether it is us going from day to day or someone following us, we move that patient progressively through our system.  We document it so that we know where the patient has gone, how they have progressed, what their status is, as well as to convey that information to others who are reading those notes.  Enforcers of Compliant Documentation Who is the enforcer of compliant documentation?  I hope you say that it is your conscience.  We all know that we all have our own values and morals.  We have our own conscience guiding us, and we know as professionals that we have certain responsibilities.  Let’s hope that this is the primary enforcer of why you document compliantly and why you are in this course. The other enforcers of compliant documentation are of course the OIG, the Feds, the Office of Civil Rights and obviously Medicare.  We also have Medicaid now as well as the Whistleblowers.  Finally, there are private payers out there that are really enforcing documentation, proper coding, and compliance with regulations.  There are a lot of players out there. The big ones are the Inspector General and The Recovery Audit Contractors.  We have some very aggressive enforcement teams with HEAT, Healthcare Fraud Prevention & Enforcement Action Team.  They really have been delivering a number of fraud and abuse cases to the forefront.  We also have other contractors from Medicare.   You know about CERT, your Medicare Administrative Contractors, and Medicare and Medicaid Recovery Audit Contractors.  We also now have the State Attorney General’s offices who have been empowered to enforce compliance against fraud and abuse. We have to think also about our license.  If you have not read your practice act and rules recently, it would behoove you to do so because more and more of the acts are being supported by rules that involve fraud abuse provisions, and things such as documentation.  Obviously supervision has been in there for a long time.  As far as remuneration, you want to make certain that you comply with the most stringent regulation!  So while Medicare may say one thing, if your practice act says another and it is more stringent, you could be in potential violation by not complying with your practice act or vice versa.  If Medicare says one and your practice act is more lenient, then you are going to have to defer to the most stringent requirement.  Documentation RequirementsThis course is specifically regarding the documentation requirements for Medicare.  This is not for other payers.  It is not for Medicaid.  It is not for Worker’s Comp.  You need to be aware of medical policies for each of them, because they can be different.  While Medicare typically is the gold standard, there can be variances, especially when it comes to whether there is a plan of care, whether there are certain supervisory requirements and time for documentation as far as submission of your records in a written or retrieval format.  So please make certain that you do look at your other payer’s medical policy and coverage policy. This is a list of the documentation elements for Medicare providers.  (Figure 3)  We have the evaluation and the certification of plan of care.  Those two may be combined.  Then there is reevaluation and recertification of the plan of care.  Those two may be combined as necessary as well.  There are also treatment encounter notes.  I refer to them as TEN, so if I lose you, we are not talking about the TENS unit.  There are progress reports and discharge summary reports.  Those are the required reports for Medicare.  Figure 3 – Slide 14EvaluationWhen we talk about the evaluation, we have very specific content requirements, and I am going to be very line item detailed so that you understand the significance of each line item requirement.  The importance of this is that Medicare has put it in writing what they do expect or mandate.  It will stipulate, and I will stipulate, whether it is required or recommended.  These items that I am listing are required elements, and they must be present in your evaluation. Diagnosis.   We typically get a...