Harmony Healthcare Blog

Nursing Documentation in Support of Therapy Services

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Tue, Jul 12, 2016

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Edited by Kris Mastrangelo


Last week’s blog on denied claim prevention spurred a ton of questions on nursing documentation, what the content should like and how to effectively make it happen.   When patients are receiving clinically appropriate Physical, Occupational and Speech Therapy Services it is important for the nursing narratives to compliment and support the rationale for therapeutic involvement. While the regulations do not offer defined parameters, some of the following suggestions are long standing industry guidelines. 

  1. Educate the House:  There is no better place to start than hosting a two week “What is Therapy?” initiative.  Rotating all employees through a 45 minute session on what OT, PT and ST Services do and how they can benefit the senior population creates a foundation of knowledge that will be invaluable for patient care.  This initiative is recommended annually while the 45 minute session can be incorporated into all facility new employee orientation. 
  1. (Onset Date) Nursing Documentation: The above process enables the Nurse to better depict which therapy is most appropriate in a given situation of patient decline or improvement. Nursing documentation establishes the foundation (baseline status) for identifying the actual onset date that the patient’s condition changed.
  2. (3 Day Rule) Nursing Documentation: In order for Therapy (and the entire interdisciplinary team) to identify a change in function (albeit an improvement or a decline), the nursing documentation in the medical record needs to be timely and accurate. Some experts recommend multiple entries describing the patient’s condition over a period of three days.  This establishes proof that the medical condition is not a “one-time aberrance” in which the team jumped to unnecessary medical intervention.

    The “3 Day Rule” is not required to establish that the patient experienced a change of condition.  However, best practices recommend multiple nursing entries in order to establish that skilled nursing observation, assessment and monitoring are ongoing, and a pattern or chain of circumstances warrants further examination by a rehabilitation trained professional.
  3. Change in Condition: The scope of changes in condition includes patient improvement and decline within a variety of areas.

    For Example: 
    • postural changes,
    • skin redness,
    • decreased/increased mobility,
    • the need for increased/decreased staff assistance to complete ADLs,
    • increased/decreased pain,
    • decreased/increased appetite,
    • weight loss, weight gain and
    • increased lethargy, 

to name a few. Through daily skilled observations of CNAs and Nurses, subtle changes in patient performance can be identified, ultimately triggering the need for a Skilled Therapy Evaluation.


Therapy Referral Checklist 

Harmony Healthcare International (HHI) encourages facilities to take a proactive approach to staff education on defining the need for initiation of therapy services.  The following lists can be super helpful when training all facility staff. 

Referrals to Physical Therapy should occur based upon the following symptoms:

  • Decreased mobility; including bed mobility or overall mobility.
  • Increased pain with movement; either active or passive.
  • Joint changes; contractures and decreased range of motion.
  • Changes in muscle tone; either increased rigidity or flaccidity.
  • Onset of increased tremors, shakiness, or knees buckling.
  • Increased assistance with transfers.
  • Gait changes; such as unsteadiness, shuffling gait.
  • Balance changes; such as loss of balance.
  • Furniture walking (holding on to furniture during attempts to walk).
  • Falls or unintentional changes in plane.
  • Dizziness.
  • Pressure areas; Stage III or IV.
  • Changes in sequencing movements; such as decreased ability to use assistive devices for ambulation. 

Referrals to Occupational Therapy should occur based upon the following symptoms: 

  • Decline in ADL independence; including the need for increased assistance toileting, self feeding, dressing, bathing.
  • Decreased trunk control or strength.
  • Postural changes; leaning in wheelchair, anteriorly, laterally or posteriorly.
  • Muscular tone changes; i.e., increased rigidity or flaccidity.
  • Decreased wheelchair mobility.
  • Skin redness to bony prominences or other areas with prolonged wheelchair sitting.
  • Increased pain in upper extremities and joints; including shoulders, hands, wrists, etc.
  • Contracture of upper extremity joints, including fingers, hands, etc.
  • Decreased ability sequencing activities of daily living, i.e. dressing, functional problem solving.
  • Positioning changes; i.e., inability to hold head up in wheelchair.
  • Decreased functional activity tolerance for ADLs.
  • Increases shortness of breath while completing ADLs.
  • Decreased ability to reach for items in immediate environment.
  • Declining cognition.
  • Decreased safety awareness.
  • Decreased visual discrimination or acuity.
  • Decreased continence. 

Referrals to Speech-Language Pathology should occur based upon the following symptoms: 

  • Decreased ability to communicate basic wants/needs.
  • Slurred or garbled speech that is difficult to understand.
  • Inability to name objects.
  • Increased lethargy.
  • Declining cognition.
  • Increased confusion.
  • Decreased problem solving of simple daily functional situations.
  • Inability to recognize familiar faces.
  • Weight loss.
  • Prolonged chewing or swallowing during meals.
  • Residual food remaining in the mouth after meals.
  • Coughing, choking, runny nose, or watery eyes during meals.
  • Decreased p.o. intake.
  • Decreased safety awareness.
  • Facial asymmetry.
  • Incidence of drooling; difficulty managing own secretions or saliva
  • Wet, gurgly vocal quality.
  • Decreased audible voice.
  • Uncoordinated respiration and swallowing during meals.
  • Decreased visual scanning.
  • Recurrent URI’s, particularly Right Lower Lobe pneumonia. 

Nursing documentation to support skilled therapy services is an ongoing focus for all providers.  It is an area that requires constant focus, training and discussion for the care givers to completely understand the value and skill they offer to the Medicare Beneficiary. This process leads to better narratives that properly reflect the skilled services rendered.

If you have questions or concerns about Nursing Documentation in support of Therapy Services, please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413. 

harmony20 October 29-30 2020 Encore Boston Harbor

Tags: Skilled Nursing Documentation

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