Behavioral health issues in skilled nursing facilities (SNFs) require meticulous documentation to ensure proper care and compliance with regulations. Accurate documentation not only facilitates effective treatment but also helps in addressing legal and regulatory requirements. Here are the top five tips for SNFs to enhance their behavioral health documentation practices.

  1. Thorough Assessment and Evaluation:

Comprehensive assessment and evaluation lay the foundation for effective behavioral health documentation. SNF staff should conduct thorough assessments of residents upon admission and regularly thereafter. These assessments should encompass various aspects of behavioral health such as mental health status, cognitive function, emotional well-being, trauma screening, and social interactions. Utilizing standardized assessment tools can help ensure consistency and accuracy in evaluations. Moreover, documenting any changes in behavior or mental health promptly is crucial for early intervention and appropriate care planning.

  1. Use Clear and Objective Language:

Clarity and objectivity are paramount when documenting behavioral health observations and interventions. Avoid vague or subjective terms and instead use specific, descriptive language. Document observable behaviors along with relevant contextual information such as triggers, frequency, and severity. Example: Instead of stating “resident appears anxious,” document specific observable behaviors such as “resident paces the hallway, wringing hands, and repeatedly asks staff about upcoming activities.” Including objective details helps convey a clearer picture of the resident’s behavior and aids in determining appropriate interventions. Additionally, record residents’ responses to interventions and any modifications made to their care plans. Objective documentation not only facilitates communication among healthcare providers but also provides a reliable record for regulatory compliance and legal purposes.

  1. Document Care Plans and Interventions:

Developing individualized care plans tailored to residents’ behavioral health needs is essential. Document these care plans comprehensively, outlining specific goals, interventions, and strategies for managing behavioral symptoms. Speak with the resident and/or authorized representatives, family, or others that can provide insight into the resident’s preferences, routine, comforts and aversions. Include input from interdisciplinary team members, such as psychiatrists, psychologists, social workers, and nursing staff, to ensure a holistic approach to care. Regularly review and update care plans based on residents’ progress or changes in their condition. Tracking intervention success enables the evaluation of effectiveness and informs future care decisions. Example: Mr. Doe’s care plan for managing aggression includes interventions such as redirection, relaxation techniques, and staff support. Each intervention is documented with details on implementation and outcomes. For instance, staff note that redirection to his favorite activity of sorting baseball cards successfully de-escalated a recent agitation episode, reinforcing the effectiveness of this intervention.

  1. Maintain Timely and Accurate Records:

Timeliness and accuracy are critical aspects of behavioral health documentation. Ensure that all entries are made promptly and accurately, reflecting the most current information regarding residents’ behavioral health status and care. Use electronic health record (EHR) systems or structured forms to facilitate organized and standardized documentation. Train staff on proper documentation practices and provide ongoing education to promote consistency and compliance. Regular audits can help identify any gaps or errors in documentation and address them promptly.

  1. Ensure Compliance with Regulations and Standards:

SNFs must adhere to regulatory requirements and industry standards governing behavioral health documentation. Familiarize yourself with applicable regulations from entities such as the Centers for Medicare & Medicaid Services (CMS) and state licensing agencies, including the State Operations Manual Appendix PP which outlines requirements for §483.40 Behavioral health services. Stay updated on changes or updates to documentation guidelines and incorporate them into facility policies and procedures. Regularly review documentation practices to ensure compliance and address any deficiencies proactively. Engage in continuous quality improvement efforts to enhance the overall quality of behavioral health care in the facility.

Effective behavioral health documentation is essential for delivering high-quality care and maintaining regulatory compliance in skilled nursing facilities. By following these top five tips, SNFs can improve their documentation practices, enhance communication among healthcare providers, and ultimately promote better outcomes for residents with behavioral health needs. Investing in comprehensive assessment, clear language, individualized care planning, timely record-keeping, and regulatory compliance will contribute to the overall well-being and satisfaction of residents.

Join us for a journey into the heart of healthcare documentation with our ongoing webinar series, “Documentation in Depth.” Take action to Improve your facility’s behavioral health documentation by joining us on February 20, 2024 for Documentation for Behavioral Health & Mental Illness. During this session, Proactive experts will continue to unravel the intricacies of accurate, timely, and standardized documentation in nursing homes while helping participants discover strategies that enhance communication, promote quality care, and ensure regulatory compliance.




Eleisha Wilkes, RN, GERO-BC, RAC-CTA, RAC-CT, DNS-CT
Clinical Consultant

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