New Documentation Guidance was included in the Jimmo Manual revisions.
- The theme is that the need for and receipt of skilled care must be evident – show that the care was skilled
- There are no magic words – but vague phrases like “patient tolerated treatment well,” “continue with POC (Plan of Care) and “patient remains stable” are NOT sufficient to establish coverage
Nurses and therapists should document what they do and why. IF improvement is occurring, note it. If the goal is, or includes maintenance or changes to maintenance, make sure that is noted in the order. If appropriate, get a new order for maintenance.