Documentation must be accurate, consistent between all sections of the EMR, and reflective of actual care and services provided. January is the right time to evaluate documentation practices and ensure that records support compliance.
Key areas to review:
- Alignment between documentation and observed care
- Consistency across disciplines
- Timeliness and completeness of entries
- Communication processes that prevent conflicting information
Surveyors frequently compare documentation to staff interviews and resident outcomes to your organization’s detriment. Strong documentation integrity reduces risk and strengthens compliance, which is why it’s Day 11 of our 12 Days of Compliance.
New Year Compliance Check:
Are your documentation audits catching inconsistencies early?
CMS Compliance Group provides documentation audits to help ensure records accurately reflect resident care. On-site and remote based options available. Call 631.692.4422 or email info@cmscg.net for assistance.
