Harmony Healthcare Blog

Top 5 Documentation Tips for Speech Cognition (Part 2 of 2)

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Tue, Jun 14, 2016

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Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

speech_therapy_2.jpgCognitive rehabilitation is distinguished from Occupational Therapy in that cognitive rehabilitation consists of tasks designed to develop memory, language and reasoning skills that can be applied to specific environments (e.g., home, work) while Occupational Therapy is rehabilitation directed at those specific environments.


Medically Necessary

Not Medically Necessary

Skilled evaluation/re-evaluation.

Routine screenings and observation.

Designing the treatment program, establishing and/or updating program goals.

Documenting results of screens.

Provision of skilled treatment techniques e.g., use of program components of LSVT or other skilled intervention to improve overall communication.

Ongoing oral-motor exercises in the absence of other skilled intervention.

Ongoing assessment and analysis related to progress toward goals.

Repetitive non-skilled documentation, such as reporting food intake amounts.

Establishment of compensatory strategies.

Routine observation, such as at a meal, providing only verbal reminders, in the absence of other skilled intervention.

Patient instruction and training in skilled techniques; modification to cueing hierarchy.

Repetitive verbal encouragement in the absence of modifying techniques and/or cueing systems.

Instructing staff/caregivers on patient participation in using compensatory strategies/ functional maintenance program for carry-over of trained techniques.

Providing verbal reminders/cues; discussions with caregivers without the patient present and participating; providing general written guidelines.


Justification for Continuing Services: 

Skilled Clinical Reasons

Non-Skilled Clinical Reasons

Patient presents with good carry-over of compensatory strategies for memory deficits, however, presents with problem solving, reasoning and planning deficits requiring 24-hour supervision. Continue ST to increase cognitive skills for home environment.

Patient unable to live independently.  Skilled ST is needed to develop skills to return home.

Patient has behavioral outbursts due to inability to communicate daily needs and ideas, but attempts to use trained strategies of choice presentation and auditory rehearsal given verbal cues. Continue ST to improve functional communication and reduce frustration.

Patient demonstrates aphasia. Continue therapy per physician’s order.


The following scales can assist clinicians with documentation to facilitate communication throughout the Interdisciplinary team. 

Fluctuations in behavior and functional abilities make it difficult to define dementia. Two scales can clear up the picture and promote better communication between Therapy and Nursing staffs: the Global Deterioration Scale (GDS) and the Allen Cognitive Level (ACL).1-2 

The seven levels of GDS, which identifies stages of dementia and impairment levels over time, reflect the severity of the condition.  The levels, ranging from no cognitive decline at level 1 to very severe cognitive decline at level 7, provide a snapshot of disease progression.  While GDS works well in interdisciplinary settings because it doesn't require testing or lengthy observations, it only identifies levels of deterioration, not function.  The ACL scale, which provides information about a patient's abilities, corresponds to GDS levels. 

Once a cognitive level has been determined, the therapist can write a Plan of Care that will help patients succeed at functional tasks and reinforce sustained performance.  It is important to look at swallowing and speech skills, ADLs, ability to follow commands, need for assistive devices, awareness of safety considerations, and ambulation. 

If nurses in a facility are using the GDS to identify dementia, therapists can use the level to integrate information gathered from the ACL and an evaluation.  The Therapy and Nursing staff can collaborate in developing treatment interventions based on a resident's cognitive level. 

There is little or no cognitive decline at GDS level 1/ACL level 5.8-6.  Residents should be able to answer questions, read instructions, and report problems.  They can learn to anticipate problems but may benefit from environmental modifications. 

At GDS level 2/ACL level 5.4-5.6, residents may have trouble remembering.  Self-cueing devices, such as notebooks and lists, can help facilitate memory.  They also may benefit from written instructions to help complete tasks and comprehend verbal instructions. 

Residents at GDS level 3/ACL level 5-5.2 can look at a clock and tell time, but they may need memory aids to keep appointments and synchronize activities.  They may act impulsively, be argumentative, or say things without realizing the social consequences. Patients at this level should be able to compensate for mild to moderate physical limitations. 

At GDS level 4/ACL level 4.4-4.8, residents obtain new information slowly.  Memory tasks are effective to facilitate recollection.  They benefit from word-finding techniques to maintain the expressive flow of communication and usually can learn a schedule because they are oriented to the day and date. 

Reading skills are starting to decline at this level, but one or two-word notes or reminders can be provided at eye level.  Use bright colors and large print for visual cues to help patients stay on task.  Patients can learn new functional tasks, but they require one-step directions and need to practice in situation-specific settings.  They respond best to visual and tactile cueing.  While patients may seem to be noncompliant and inflexible about the way they do things, it is merely a defense mechanism because of the difficulty they are experiencing in learning new material. 

Residents at GDS level 5/ACL level 3.6-4.2 may be disoriented about the date and time of day, but they can still measure the passage of time by the activities they have completed, such as getting dressed and eating meals. A large calendar can serve as a reminder. They recognize the difference between friendly and unfriendly social greetings and can make choices if they are given an either/or option. 

Patients at this level also can perform self-care if it is a habitual activity that does not require change, but they may need two to three times the normal amount of time to complete the task.  Supplies for self-care routines should be within arm's reach, with objects organized from left to right.  Patients can learn to use adaptive equipment successfully if the task is familiar and moderate verbal cues are provided. 

Residents speak in short phrases at GDS level 6/ACL level 3-3.4 and may be able to follow commands to start and stop actions.  They can be assisted to write and recognize objects by size, color and shape.  Hand movements are only briefly sustained and usually are carried out in a back-and-forth motion. 

Patients respond well to the calming effects of music at GDS level 7/ACL level 2-2.8. They can learn songs incorporated with actions, such as clapping, and enjoy activities, such as dancing, marching and rocking.  Their vocabulary shrinks to only a few words, so they may communicate through gestures.  They should be asked only yes-or-no questions. 

Patients demonstrate a heightened response to loved ones and favorite items at this level. They can use utensils for feeding, with appropriate cues; but caregivers should precut food and fill a cup halfway to decrease spills. 

Evaluating and treating residents who are cognitively impaired can be demanding.  Practitioners should not be reluctant to treat these patients out of concern that an intermediary may deny payment because of a diagnosis of Alzheimer's disease.  Under Medicare, a dementia diagnosis does not restrict a beneficiary from receiving therapy. 

Reference:  Advance for Speech Language and Audiology, Vol. 15 Issue 34 titled Goal-Setting in Dementia; Tap into remaining abilities, By Ellen Strunk and Sharon Host.

Missed Part 1 of this blog series? Read it here.  If you have questions about Speech Cognition Documentation, please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413. 

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Tags: Speech Therapy, cognitive therapy, Speech Cognition

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