Harmony Healthcare Blog

5 Tips to Improve Therapy Documentation

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Fri, Jun 21, 2013

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Edited by Kris Mastrangelo

In light of the recent surge of medical record reviews by the federal government, therapists and providers need to sharpen their skills on ensuring that the therapy documentation justifies the services rendered.  The following quick tips should aide in this quest.

1. Evaluations: 

Therapy evaluations are not only required prior to treatment, they are also a tool for the government to ascertain whether or not the services are reasonable and necessary.  Evaluations establish the physical and cognitive baseline data necessary for assessing expected rehabilitation potential, setting realistic goals, and measuring progress.  Objective tests and measurements are extremely valuable to establish preliminary clinical status.

The keen eye of a therapist is extremely valuable in establishing a patient’s potential.  This prediction is based upon many factors which include, but not limited to, prior level of function, diagnoses, co-morbidities, medications, and age.  Therapy evaluations sans treatment need to be revisited as the establishment of a maintenance program is a skilled service.  Evaluations are a key catalyst to the therapeutic regimen affording optimal patient care.

2. Functional Limitations:  Describe why the patient needs help:

Functional limitations need to be depicted in the therapy notes in order to support skilled services.  Too often, therapists write “Patient requires minimal assistance with Toilet Transfer,” but they do not tell the reader why the patient requires assistance.  Per the Medicare Manual, skilled intervention is supported when the patient requires assist and requires functional training, observation, assessment, or environmental adaptation, due but not limited to: 

  • Lack of awareness of sensory cues, or safety hazards
  • Impaired attention span
  • Impaired strength
  • In-coordination
  • Abnormal muscle tone
  • Range of motion limitations
  • Impaired body scheme
  • Perceptual deficits
  • Impaired balance/head control
  • Environmental barriers

Hence, it is imperative that therapists elaborate note writing to define the etiology for therapeutic interventions.  Within this context, the therapist also needs to demonstrate why the daily skills, knowledge and judgment of a trained professional are required.

3. Safety: 

Safety issues are a top priority in health care.  A safety problem exists when the patient is unable to handle himself in a manner that is physically and/or cognitively safe unless the therapist is involved.  This may extend to all aspects of daily living as well as added secondary complications which may intensify the medical sequelae (such as skin breakdown.)

4. Plans of Treatment:  

The therapy plan of treatment must include specific functional goals and a reasonable estimate of when they will be reached.  It is not adequate to estimate 1-2 months on an ongoing basis.  Aspects that must be addressed in the plan of treatment include:

  • Type of Therapy Procedures: Describes the specific nature of the therapy to be provided (ADL training, gait training, therapeutic exercises, etc.)
  • Frequency of Visits: An estimate of the frequency of treatment to be rendered (e.g., 3x per week).  In addition, the provider's medical documentation should justify the intensity of services rendered. This is crucial when the orders are given more frequently than 3x per week.
  • Estimated Duration: Identify the length of time over which the services are to be rendered in days, weeks, or months.
  • Diagnoses: Includes the therapy diagnosis and the medical diagnosis. The therapy diagnosis should be based on objective tests, whenever possible.
  • Functional Goals: Reflects the therapist's and physician's description of what functional, physical and cognitive abilities the patient is expected to achieve.  Assume that factors may change or influence the level of achievement.  If change occurs, the therapist or physician explains the factors which led to the modification in functional goal(s).
  • Rehabilitation Potential: The therapist's and physician's expectation concerning the patient's ability to meet the established goals.  Please note, this potential is in direct relation to the patient-specific goals.

5. Progress Notes: 

Weekly progress reports and treatment summaries need to address the following:

  • The patient's initial functional status
  • The patient's functional status and progress (or lack thereof) specific for the reporting period; including clinical findings (amount of physical and/or cognitive assistance needed, range of motion, muscle strength, unaffected limb measurements, etc.)
  • The patient's expected rehabilitation potential

Where a valid expectation of improvement exists, the services are covered even though the expectation may not be realized.  Progress reports or status summaries must document a continued expectation that the patient's condition will continue to improve significantly in a reasonable and generally predictable period of time.  With the advent of the Jimmo Settlement, “the improvement” criterion has been elaborated and will be addressed in a future blog article.

Source:  Medicare Benefit Policy Manual, Documentation Requirements for Therapy Services – Section 220.3 (Rev. 165, Issued: 12-21-12, Effective: 01-01-13, Implementation: 01-07-13)

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Tags: Documentation, Therapy

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