Have you been SPOOKED by the recent implementation of PDPM?

The recent implementation of PDPM has been a scary time for all and while the focus seems to be back on nursing, so are the challenges. One such challenge is enhancing the quality of supportive documentation.

Documentation in the patient’s medical record must reflect the need for the skilled services provided, and should also convey important communication among the interdisciplinary care team regarding person-centered care plan development, the course of treatment, and outcomes of the skilled observations, assessments, care and services, and skilled training performed.

Old habits die hard and often come back from the dead…With the former reliance on therapy as the primary skilling service, facilities may face challenges in driving sustained improvement in charting that reflect daily skilled nursing services and support both the nursing case mix group and the non-therapy ancillary (NTA) component with documentation of the clinical support for these portions of the PDPM per diem. With the shift away from therapy treatment time as the primary driver of payment, greater scrutiny of nursing supportive documentation for active conditions, Nursing Case Mix Group variables, NTA items, the GG Function Score and, of course, medical necessity for SNF level of care will be expected.

Consider adding these to your bag of tricks (and treats)!

Proactive Resources for PDPM Documentation Improvement:
  • Join us live on November 5th or 6th for the Moving Mountains webinar – “Skilled Nursing Supportive Documentation for PDPM”
  • On-Demand PDPM Skilled Nursing Services webinar focused on justifying skilled nursing services under PDPM! This session is available on-demand to jump start your team’s skilled charting. Click here to access. 
  • Check out our PDPM Nurse Charting Guidelines including documentation guidance for critical NTA item supportive documentation as well as Clinical Categories!

Have questions? Contact us to learn how we can help with your PDPM transition.

Webinar: PDPM Skilled Nursing Supportive Documentation for Skilled Level of Care

This 1.25 hour webinar will focus on skilled nursing documentation requirements and best practices as it relates to the new Medicare payment model – PDPM. The webinar will include review of skilled level of care criteria with an emphasis on skilled nursing services and documentation to support the skilled stay. Click here to learn more about this product in our shop.

PDPM Skilled Nursing Charting Guidelines

This resource provides PDPM Skilled Nursing Charting Guidelines for condition/service specific NTA items and by Clinical Category with actual skilled documentation examples. Include these PDPM Charting Guidelines as part of your skilled nursing education to promote quality documentation to support the nursing care and services provided. Click here to learn more about this product in our shop.


Get more resources in our shop!

Patients rely on you. You can rely on us. Find toolkits, webinars, on-demand trainings, templates, and much more to meet the needs of your facility. Click here to visit our shop.

Blog by Eleisha Wilkes, RN, RAC-CT, Clinical Consultant, Proactive Medical Review

Click here to learn more about Eleisha and the rest of the Proactive team.