Working together for the best clinical outcomes and for reimbursement accuracy requires good systems for communication – both verbally and in our documentation. The fundamental expectations for documentation to support skilled level of care, medical necessity, and appropriate intensity and duration of services remain critical under PDPM. One step to ensuring optimal patient outcomes is understanding the role of interdisciplinary team members in collaborating to manage complex conditions and supporting skilled services related to those conditions through effective documentation.

Check out our recorded webinar: All In! PDPM Supportive Documentation for Physicians, Nursing, Rehab, Dietary, and Social Services for an overview of documentation requirements and tips including:

Physician Documentation

      • Need for 24-hour, inpatient care detail
      • Discharge plan with timeframe and any specific obstacles to discharge
      • Rehab intensity expectation
      • Active diagnoses and conditions
      • Timely signatures and dates (orders, POC, CERTs)
      • Close oversight of skilled stay

Nursing Documentation

      • Daily skilled need detail – Skilled Therapy, Skilled Nursing, Assessment and Observation, Management of the POC, and Teaching and Training
      • Functional status and changes from PLOF (Section GG)
      • Specific medical condition management including Primary Diagnosis (Clinical Category) and secondary conditions (comorbidities)
      • Reason(s) for inpatient need vs. home health, outpatient or other care settings

Therapy Documentation

      • Objective measures of impairment
      • Skilled interventions/Patient response
      • Complexities and comorbidities impacting treatment
      • Skilled teaching consistent with new learning ability
      • Compensatory strategies and skilled treatment interventions
      • Functional impact and progress
      • Safe discharge transition

Nutritional Services Documentation

      • Swallowing Disorders
      • Mechanically Altered Diet (including thickened liquids)
      • Parenteral/IV Feeding
      • Enteral Nutrition/Feeding tube
      • BMI/Weight loss

Social Services Documentation

      • Brief Interview for Mental Status (BIMS)
      • Patient Health Questionnaire (PHQ-9)
      • Staff Assessments for Mood and Mental Status
      • Behavior recognition and management
      • Trauma Informed Care
      • Signs and symptoms of delirium
        • Family/Representative Collaboration and DC Planning


Interdisciplinary team documentation is an in-depth topic. Additional Proactive resources to support your facility are available at the links below:


Blog by Eleisha Wilkes, RN, RAC-CTA, Proactive Medical Review

Learn more about Eleisha and the rest of the Proactive team.