Lecture 5: Documentation

Question 1

What are 4 purposes for documentation?

Answer 1

1. Legal record of pt management
2. Communication
3. Demonstrate clinical problem solving and EBP
4. Reimbursement

Question 2

What 7 items must documentation include according to the CMS documentation guidance?

Answer 2

1. Hx and Physical exam pertinent to pt’s care
2. Skilled services provided
3. Pts response to skilled services during current visit
4. Plan for future care based on rationale of prior results
5. Detailed rationale and the need for skilled service in light of pt’s overall medical condition/experience
6. Complexity of service to be performed
7. Any other pertinent characteristics that impact the PT’s POC or outcome of care

Question 3

What describes Skilled Therapy documentation?

Answer 3

• clinical decision & problem solving process
• answers the “why”
• connect intervention to body function/structure & to goals
• Document safety issues
• Pt’s response
• Don’t make it too repetitive

Re-read your own documentation

Question 4

Unskilled therapy documentation

Answer 4

• tolerated treatment well
• continue per POC
• interventions that aren’t skilled
• improve general fitness or endurance
• continue per MD orders

Question 5

What are the (8) documentation guidelines?

Answer 5

1. Every visit
2. Compliant with state jurisdiction
3. Facility policy for making addendums
4. Only approved abbreviations
5. All pages have name of client, therapist w/ credientials, and date
6. Document no shows
7. within 24 hours
8. Medically necessary and demonstrates skilled interventions

Question 6

What are the Top 10 Payer complaints?

Answer 6

1. Poor legibility
2. Incomplete documentation
3. No documentation for date of service
4. Too many abbreviations
5. Doesn’t support the billing
6. Doesn’t demonstrate skilled care
7. Doesn’t support medical necessity
8. Doesn’t demonstrate progress
9. Repetitious daily notes - no change in pt status
10. Interventions w/ no clarification of time, frequency, duration

Question 7

Red Flags of Documentation

Answer 7

1. Ranges of level of assistance
2. Little progress noted or status unchanged
3. Patient agitated or confused
4. > 3 modalities or modalities after 4th visit
5. Poorly written goals or POC
6. Testing too often or not reported
7. No documentation of exercise or education

Question 8

What are the types of PT documentation?

Answer 8

• Initial Eval
• Re-eval
• Daily Notes
• Progress Notes
• Discharge Notes
• Other (Letters of medical necessity, notes to other providers)

Question 9

Pt reports having to limit standing to approx. 10 minutes at a time due to pain. In what part of the ICF model would this fit?

A. Body structure and function
B. Personal factor
C. Activity
D. Participation

Answer 9

C. Activity