The purpose of documentation is to provide a record of services rendered to support medical necessity, including that services are skilled, rehabilitative, safe and effective. Documentation provides factual information for administrative, regulatory, billing and payment as well as for clinical purposes.
Therapists need to document support that therapy services are needed due to:
o The functional deficits with which the patient presents, i.e., decreased Activities of Daily Living (ADLs) functions
o The impairments identified that cause the functional deficits, e.g., decreased ROM, decreased flexibility, etc. - the Problem List
Documentation to support that the patient would benefit from therapy services in order to:
o Return to previous level or near previous level of function
o Prevent further deterioration or decreased risk factors
o To provide evidence that progress is made during the treatment as relates to both the functional deficits (ADL measurable progress) and measurable impairments (increases in ROM, etc.)
Documentation must support that billing is appropriate by using the appropriate coding per payor and for Medicare, the 8 minutes rule and documentation of Total Times
The Initial Evaluation and Plan of Care demonstrate Medical Necessity and need for Skilled Therapy by:
o Describing the onset of the illness, disease, or exacerbation of a chronic condition
o Painting a picture of the patient's baseline condition - the Prior Level of Function with specific ADLs, e.g., the patient was able to ambulate for 60 minutes to grocery shop
o Documenting the patient's Current Level of Functions with specific ADLS, e.g., the patient is unable to ambulate for more than 5 minutes, a neighbor grocery shops for the patient
o Providing information regarding the patient's living environment, i.e., does the patient live alone? does the patient need assistance for ADLs? are there stairs in home?
o Providing objective measurements to support the need for skilled care. The use of standardized tests should be scored to establish and support a baseline for function and uses to evaluate the patient.
A consistent flowing SOAP note is SO important when it comes to proving medical necessity.
Subjective:
o Age of patient - can be a complexity
o Date of onset - can be a complexity. Use date of last exacerbation or time that patient saw physician for referral, not "insidious."
o Current complaint & history of the complaint
o Pain - include the description, type, intensity - use a pain scale
o Prior Level of Function (PLOF) - use Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)
o Current Level of function (CLOF) - use ADLs/IADLs, include use of assistive devices
o Aggravating and ameliorating factors
o Medical History/Medications - both can contribute to complexities
o Complexities/Co-morbidities - document all that might impact the course of the treatment. (This could impact medical necessity for extending treatment beyond the CAP.) Include specificity regarding the severity of the complexity/co- morbidity.
o Precautions - also document on the treatment log at the top in red for continuity of care
o Prior Therapy and the outcome
o Living arrangements - e.g., Live alone? Need assistance from others? Caregiver? Stairs in/out of home? Steps in/out of home? Handrails present-what side?
Objective:
o Measurements
o Tests - use standardized tests whenever possible for functional assessment, e.g., Patient Specific Functional Status and impairments, Tinetti
o Observations - i.e. gait, skin integrity, neurological status, cognitive status, how the patient:
o Sits - posture
o Transfers from sit to stand
o Balances
o Ambulates - distance ambulated, devices used
o Gait - comparison of stance phase and stride length, cadence, ascend and descend stairs
o How patient takes off coat or sweater
Assessment: clinical judgment/subjective impressions
o Problem list - what are the problems Therapy can help?
o Therapist's treating diagnosis
o Patient's overall condition
o Determination if treatment is or is not necessary
o Why skilled care is necessary, i.e., Therapy problem list
o Level of any verbal and physical assistance
o Goals - measurable functional (based on ADLs/IADLs), include:
oShort Term Goals (STG) with timeframe
o Long Term Goals (LTG) with timeframe
Plan of Care:
o Treatment choices AND why chosen
o Frequency & duration
o Diagnosis, goals, discussed with patient statement
o Physician/NPP certifying statement
GOALS:
Goals should be:
o Consistent with the identified impairments and the previous functional level of the patient
o Clearly identified both for the Short Term Goals (STGs) and the Long Term Goals (LTGs), e.g., LTG 1.,2.,3. and STG 1.a, 2.a, 3.a or LTG 1.,2.,3. and STG 1., 2., 3.
o Measurable, i.e., # of feet, minutes, amount of assistance needed, # of pounds
o Suggest a STG - Initiate HEP and a LTG - Finalize HEP
o Suggest using STG - documents progress
Examples:
o STG 1 in 2 weeks: Pt will be able to stand at the sink to prepare a small meal
o LTG 1 in 4 weeks: Pt will be able to stand in the kitchen for 30 minutes to prepare a large meal
o STG 1 in 2 weeks: Pt will be able to reach the first shelf in the kitchen to remove a cup
o LTG 1 in 4 weeks: Pt will be able to reach the second shelf in the kitchen to remove a plate
o STG 1 in 2 weeks: Pt will be able to grasp and lift a cup to drink
o LTG: in 4 weeks: Pt will be able to grasp a 1-2 lb pan and lift to stove
Document all of the possible modalities you may use. "Modalities as needed" is not adequate.
Review the FI/MAC/Carrier local coverage determinations (LCDs).
Explain why you chose to use the various treatments/modalities.
As treatment progresses, document in the daily notes and ProgressReports, Evaluations/POC:
o Treatment modifications: document why you are discontinuing and changing to the new exercise/modality
o Your focus of the treatment when using the same exercise for different reasons, e.g., one day the exercise is focused on neuro re-education and the next, the same exercise is focused on increasing ROM
o Major changes to the treatment plan require physician/NPP Re-Certification.
Ask yourself:
o Does my documentation show that the treatment provided could only be given by a licensed Therapist?
o Am I reassessing the progress toward the identified goals?
o Was the treatment maintenance in nature?
o Does my documentation establish a distance baseline of function and clearly show how my patient is responding to the treatment provided and is progressing?
o Am I treating for pain without documentation regarding the severity of the pain and use of a pain scale?
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