Course Description:

Accurate, comprehensive documentation is the foundation of quality care, regulatory compliance, and financial integrity in the SNF setting. This presentation equips DONs with the essential knowledge and oversight strategies to ensure clinical documentation meets federal, state, and facility standards. Participants will explore the DON’s role in guiding interdisciplinary documentation practices, supporting accurate MDS assessments, and mitigating risk through effective monitoring systems. This session will also cover common documentation challenges, expectations, and practical approaches for coaching nursing staff toward excellence in clinical recordkeeping.

Learning Objectives:

1. Identify key requirements related to SNF documentation.

2. Describe the DON’s leadership role in establishing and monitoring documentation standards.

3. Recognize common documentation deficiencies and implement prevention strategies.

4. Strengthen documentation systems, staff accountability, and survey readiness.