Bullet Proof Documentation E-Book
Documentation is something we do everyday. It can seem like a mundane chore, but it is crucial to make sure we get it right. Whether it’s for another therapist reading our notes, insurance justification for services or legal proceedings, the accuracy and details of your notes matters. This ebook will give you the tools to make your notes bullet proof.
We start with a list of some Do’s and Dont’s. We all pick up bad habits that make our notes faster. But there are some things we need to make sure we incorporate into our notes to keep them compliant with insurance guidelines and legal proceedings.
When documenting in the objective portion of your notes it’s important to include 4 elements in your descriptions. What you did, Why you did it, How long you did it for, and What makes it a skilled service. This will aid in the justification of the selection of your tasks.
Everything you need to make your notes stand up to scrutiny in legal proceedings, insurance review and coworker crossover is included in this book.
You might know the 8 minute rule, but do you know the Medicare roll-over rule? This rule counts our units differently than the 8 min rule. If you are adding up units for your Medicare patients with the 8 min rule you are out of compliance with Medicare guidelines.
We also include examples for each section of your SOAP note, including evaluation and orthosis fabrication notes. This gives you clear and repeatable patterns you can apply to your notes to become faster as you start using these principles in your notes.
