9. Weak vs. strong documentation
Weak — does not survive | Why it fails | Strong — defensible |
|---|---|---|
“Restorative done.” | No technique, minutes, assist level, tolerance, or goal — O0500 unsupported and the skilled need unproven. | The ambulation model note in §3: technique, distance, assist, minutes, days in the look-back, tolerance, RN evaluation, and the O0500/GG linkage. |
“Ambulated in hall.” | No distance, device, assist, or minutes — reads as a walk, not a program. | “Ambulated 75 ft with a rolling walker and contact-guard ×1, 20 min, 6/7 days per the program, tolerated (SpO₂ 96%).” |
Restorative charted as therapy | Miscategorizes the service and the PDPM component. | Document restorative as nurse-directed (O0500/nursing component); route skilled-therapy episodes to the clinical reference. |