Perspectives

  With electronic health records (EHR) rapidly replacing paper records, the use of the copy and paste function in clinical documentation has significantly increased as well. While this practice may have some time-saving benefits, it can also damage the integrity of the patient record. Inappro... [More]

Problems with documentation in skilled nursing facilities (SNF) often lead to claim denials that can negatively impact cash flow and make these facilities susceptible to audits. According to findings in the 2017 Comprehensive Error Rate Testing report, one of the most common errors in medical reviews is missing or insufficient physician certification and/or recertification statements. [More]

In November, the Centers for Medicare and Medicaid Services (CMS) announced it would give SNFs more time to adjust to some of the regulatory changes in LTC requirements before being penalized. Previously, the agency said it would restrict enforcement for one year, but due to readiness concerns from long-term care providers, they have extended their moratorium on penalties to 18 months.[More]

Nutrition is major focus at many nursing facilities because it is often linked to medical conditions. Malnutrition and dehydration, in particular, are recurring issues at nursing facilities, especially because they can lead to falls, the development of pressure injuries and/or cognitive impairment. [More]

Falls are an enormous issue in long-term care facilities, and are often at the heart of lawsuits against care providers. The medical record is a crucial tool for the defense as it pieces together a timeline of what happened before, during and after a fall. It is imperative to document all of the steps the provider took to demonstrate its awareness of the resident’s fall risk, attempts to prevent them from falling, and response when a fall does happen. [More]