Four Things to Document for Audit Proof Maintenance Care

Last week in the blog we discussed how to qualify a patient for maintenance care.Simply being on service for a long time does not mean a patient is automatically a “maintenance care” case.If you missed last week’s blog, you may view the MAINTENANCE CARE DECISION TREE HERE.

Now, if you have determined your patient meets the criteria for maintenance care, the type of documentation in your chart must be carefully reviewed.We suggest clinical documentation should be done as if every chart will be audited.  When providing maintenance care there are four things that need to be charted in every episode provided to ensure your documentation is audit proof.

  • Document why the program requires the skill of a clinician to provide the service.
  • Document the patient’s condition, the state of stability achieved, and exactly what you intend topreserve or maintain.
  • Document what decline in patient status would indicate the re-engagement of restorativeservices.
  • Document home bound status specifically charting what stops the patient from getting equivalent services outside of the home?

OperaCare has a suite of evidence-based care pathways available to our subscribers including maintenance care.We also offer education to providers on gathering evidence-based practice for care planning to improve overall patient outcomes and streamline the quality assurance process. 

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