Invincible Documentation: Super Tips, Techniques and Templates
Your protection: Identifying efficient ways to make meaningful changes in medical necessity documentation practices.
May 15, 2008 Workshop Description
This educational workshop is designed for clinicians and administrators working in or referring into inpatient rehabilitation facilities (IRFs). The education is intended to provide practical recommendations for changing documentation practices to justify IRF level care. The workshop is aimed at providing evidence to support medical necessity for IRF admissions and ongoing compliance with Medicare’s conditions of participation and medical necessity criteria. Recommendations will be made to enhance specific aspects of documentation including: pre-admission screen, history and physical, initial therapy assessments, nursing initial evaluation, care plan and daily notes and team conference notes. Methods for integrating IRF-PAI data into documentation practices will be discussed. Tips for narrative note writing, techniques for implementing changes, and templates to standardize documentation will be presented.
Note: A continuing education application has been submitted to the Association of Rehabilitation Nurses (ARN) for 5.75 contact hours. ARN is accredited as an approver of continuing education in nursing by the American Nurses’ Credentialing Center’s Commission on Accreditation. Continuing education contact hour applications have also been submitted for Physical Therapy, Occupational Therapy, Speech Language Pathology, and Social Workers. May 15, 2008 Marianjoy Rehabilitation Hospital Wheaton, Illinois
Invincible Documentation: Super Tips, Techniques and Templates Workshop Goal and Objectives May 15, 2008 Presenter: Dr. Pam Smith
Workshop Goal The Goal of the workshop is to provide participants with an assimilation of critical, medical record documentation components and strategies to support invincible, medical necessity evidence for inpatient rehabilitation facility admissions and services. Workshop Objectives
Following this workshop, participant will be able to: 1. Outline the Medicare conditions of participation for inpatient rehabilitation facility services with cited examples of compliance. 2. Define the roots of medical necessity criteria published through Medicare policies, rules, and regulations that govern Medicare beneficiaries’ admissions and rehabilitation that are medically reasonable and necessary. 3. List data items to be added to pre-admission or referral screening forms to support medical necessity criteria. 4. Describe key components of history and physical documents that highlight impairments and disabilities to be treated by a multidisciplinary, inpatient rehabilitation program team. 5. Discuss therapy initial evaluations that justify need for multidisciplinary skilled services and longterm patient goals needing an IRF level of intensity. 6. Summarize the elements of a rehabilitation nursing history that set it apart from a medical surgical nursing history. 7. Identify rehabilitation nursing interventions that provide evidence of specialized care and contributions to the coordinated, multidisciplinary plan of care. 8. Describe practical strategies for documenting therapy and rehabilitation nursing care that are consistent with the conditions of participation and other Medicare rules and regulations. 9. Explain how to apply medical necessity criteria in meaningful changes to documentation of team conferences throughout the inpatient continuum. 10. Give examples of Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and information to strengthen medical necessity documentation and focus any compliance auditing.
May 15, 2008 Marianjoy Rehabilitation Hospital Wheaton, Illinois
Invincible Documentation: Super Tips, Techniques and Templates Workshop Agenda May 15, 2008 Presenter: Dr. Pam Smith 8:00 – 8:30 8:30 – 8:45 8:45 – 10:15 Registration and continental breakfast Welcome, introductions and overview Overview of Medicare conditions of participation and medical necessity Clinical evidence of documentation compliance A template for pre-admission or referral screening An H&P template that builds on pre-admission screening data Break Therapy initial evaluations and need for multidisciplinary skilled services Nursing initial evaluations and need for specialized, skilled care Well-coordinated programs of care Lunch and facility tour Rehabilitation nursing interventions, carry-over and daily notes A template for team conference Break Integrating IRF-PAI data elements into key aspects of documentation IRF-PAI data and medical necessity Clinical notes that support scoring and coding Auditing strategies for compliance verification
10:15 – 10:30 10:30 – 12:00
12:00 – 1:00 1:00 – 2:15
2:15 – 2:30 2:30 – 4:00
May 15, 2008 Marianjoy Rehabilitation Hospital Wheaton, Illinois
Registration Form Invincible Documentation: Super Tips, Techniques and Templates
May 15, 2008 Registration Fee Location $249 on or before April 18; $299 after April 18 Marianjoy Rehabilitation Hospital 26W 171 Roosevelt Road, Wheaton, IL 60187 Please fill out this form: Name: Facility: Address: __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Phone: E-mail: __________________________________________________________ __________________________________________________________
Payment options: Credit Card, PO, Check Call 716-630-0063 for a PO or Credit Card. Mail Check to: IT HealthTrack, Inc., 6500 Main St, Suite 3, Williamsville, NY 14221 http://www.ithealthtrack.com/InvincibleDocumentation.html
May 15, 2008 Marianjoy Rehabilitation Hospital Wheaton, Illinois
Local Area Hotels for Marianjoy Rehabilitation Hospital
We have reserved a block of rooms for the Training Workshop at the following hotel, but you must call and make your own reservations. Be sure to mention Marianjoy to get the special rate. The rooms are available for two nights, May 14 and 15, 2008. Shuttle service to the hospital is available. Holiday Inn Hotel & Suites 150 South Gary Avenue Carol Stream, IL 60188 Reservations: 1-800-972-2494 Rate: $101.95, single or double Shuttle reserved for 8 a.m. departure from hotel and 4:45 p.m. pick-up at Marianjoy on May 15. As an alternative, the following hotel is also in the area. They were not able to hold a block for us, so you will need to email Nathan Karsten (nkarsten@naperselect.com) to check availability and room rate. (Be sure to mention Marianjoy.) Holiday Inn Select 1801 N. Naper Blvd. Naperville, IL 60563 (630) 505-4900 www.naperselect.com Rate: to be determined Call to schedule the shuttle. Regular taxi service is also available at this hotel.
Transportation to and from O’Hare
For transportation to and from O’Hare, you can make a reservation with a limousine company or take a taxi. Two limousine companies are listed below. Rates are very competitive. My Chauffeur Limousine Reservations: (630) 920-8888 www.mychauf.com Bluebird Limousine Reservations: (630) 848-2061
May 15, 2008 Marianjoy Rehabilitation Hospital Wheaton, Illinois