Documentation Strategies for
Nurses and Therapists
January 2, 2007 at 1:00 EST
Lisa Bazemore, MBA, MS, CCC-SLP
Setting the Stage
• Why do we document care?
 To insure payment for the services rendered
 To insure continuity of care
• Principles of documentation:
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Document to your audience
Focus on deficits
Attainable goals
Progress towards goals
Consider barriers to discharge
Consider return to both home and community
Setting the Stage
• What is Medical Necessity?
 A course of treatment that is seen as most helpful for the
specific health symptoms that the patient is experiencing.
This course of treatment is determined by the patient and
their healthcare team.
Setting the Stage
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7 Criteria of Medical Necessity
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5.
6.
7.
Medical Supervision
24 Hour Rehab Nursing
Relatively Intense Level of Services
Multidisciplinary Approach
Coordinated Care Plan
Significant Practical Improvement
Realistic Goals
Components of Medical Necessity
• Close Medical Supervision
 24 hour availability of a physician
 Entries in the chart every 2 -3 days minimum
 Greater involvement that in other settings
Components of Medical Necessity
• 24 Hour Rehabilitation Nursing
 Need availability of an RN with rehab experience around the clock
 Have clear, functional rehabilitation goals
 Nursing is involved in the overall plan of care, not just medical issues
and bowel and bladder management
 Nursing documentation supports FIM scores
 Nursing documentation clearly identifies how they facilitate the
carryover of learning from therapy sessions
 Nursing documentation supports the medical management of the
patient
Components of Medical Necessity
• Relatively Intense Level of Rehabilitation Services
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The 3 Hour Rule
Minimum of 3 hours of therapy, 5 days per week
Therapy is at a skilled level
Must be necessary for meeting the basic needs of the patient’s health
Must be consistent in type, frequency, and duration
Consistent with the patient’s diagnosis
Components of Medical Necessity
• Interdisciplinary Approach
 Members work collaboratively to develop goals and the treatment
plan
 Team members engage and learn from each other
 Collaborative ownership of the patient treatment plan
Components of Medical Necessity
• Coordinated Plan of Care
 Records need to show a treatment plan that is:
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Derived from team assessment and patient expectations
Identifies STG’s and LTG’s
Defines how disciplines share responsibility
Supports need for intensive rehab services
Weekly team conference
Components of Medical Necessity
• Significant Practical Improvement
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We do not expect 100% independence for all rehab patients
We do expect reasonable, practical improvement
Improvement must be the result of skilled services provided
Important that it is documented clearly
Components of Medical Necessity
• Realistic Goals
 Aim of treatment needs to be achieving the maximum level of
function possible
How Do We Document Medical Necessity?
• Team has an ongoing opportunity to document medical
necessity. This is achieved by documenting:
 That services needed are of a complex nature that they require a
licensed clinician
 Services need to be in an inpatient setting
 Services are consistent with diagnosis, need, and medical condition
 Services are consistent with the treatment plan
 Services are reasonable and necessary
 Patient is making progress towards reasonable goals
Where Do We Document Medical Necessity?
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Pre-admission Screening
Team Admission Assessments
Nursing Admission Assessments
Patient Care Plan
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Long term goals
Short term goals
Identification of involved disciplines
Weekly progress notes
Discharge summaries
• Team Conference Summaries
Preadmission Screening
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Diagnoses
Comorbidities
Age
Current interventions
Functional Assessment
Vitals
Safety
History
Meds
• Pre-morbid status/function
• Recommendation of need for 3
therapies
• Recommendation of need for 2
disciplines
• Rehab potential
• Areas where improvement is
expected
Preadmission Screening
Pre-morbid function: Pt. lives w/wife. Independent
with ADLs, shopping, financial management, and
recreation activities prior to onset of stroke.
Example
Rehabilitation potential: Pt. has good potential for
rehabilitation. He has shown some return of
function, has good family support, and has a desire to
get back to life as it was before his stroke.
Team Admission Assessment
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Prior level of function
Required assistance
Living situation
Anticipated D/C plans
Patients rehab expectation
Individual FIM’s with emphasis
on findings
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ROM and Strength limits
Sensation, tone, etc.
Community reintegration
Pain assessments
Summaries of findings
Poor Team Admission Example
Date: 4/3
Initials: MSM
FIM
Date:
Initials:
FIM
Meal assessed: (B) L D
Current diet: soft
Intake mode: oral
Food texture: soft
Thickened liquids No
Thickness:
Dentures edentulous
Finishes meal timely
Able to open packages
Able to scoop
Able to take food to mouth
Able to cut
Noted:
Choking
Eating
Coughing
Neglect
Swallowing precautions:
Bedside swallow results: (Y)
Swallow study results: Y
Adaptive Equipment Needs:
Findings:
Pt without dentures
Positioning needs:
Safety Needs Identified:
See bedside swallow eval
5
Why This Is Poor
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No indication that skilled intervention is needed
All items were not assessed
No safety needs identified
Findings do not provide justification for skilled therapy
No indication of why FIM was 5
No indication that intervention was needed on an inpatient basis
No indication that an interdisciplinary team is needed
Poor Team Admission Example
Toileting
Date: 1/3/04
Initials: MEM
FIM
Date:
Initials:
FIM
Able to pull clothing down
Able to pull clothing up
Able to manage hygiene – Bladder
0
Able to manage
closures
Able to manage hygiene – Bowel
Able to follow precautions (i.e., Hip)
LIMITATIONS
NOTED IN:
Balance
Coordin
ation
Adaptive Equipment Needs:
Findings:
Pt did not have to void on eval
Safety
ROM
Sequencing
LE
Strength
UE
Strength
Problem
Solving
Why This Is Poor
• Toileting was not assessed – this is an important area for
assessment to establish the medical necessity for OT
Poor Team Admission Example
Summary Of Findings:
Overall clinical impression/rehab potential (qualified)
Supportive family, will need supervision at home post rehab
SW
Initials: ___
SLP
Initials: ____
Recommend speech tx with focus on cog-ling tasks. Fair rehab potential to return home with
supervision.
OT
Initials: ____
Pt to benefit from OT 5-6x/week for ADLs, transfers, strength/endurance to return home
with family with supervision as appropriate
PT
Initials: ____
Nursing
Initials: ____
Good to return home alone after rehab with support services as needed.
Why This Is Poor
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SW does not indicate need for skilled social services
SLP does not link need for therapy w/return home potential
PT does not show need for skilled therapy services
No indication that 24 hour setting for intervention is needed
Improved Example of Team Assessment
Date: 4/3
Initials: MSM
FIM 4
Date: 4/4
Initials: LF
FIM 4
Meal assessed: (B) L D
Current diet: soft
Intake mode: oral
Food texture: soft
Thickened liquids No
Thickness:
Dentures yes
Finishes meal timely N
Able to open packages
Setup
Able to scoop Ind
Able to take food to mouth I
Able to cut Mod A
Eating
Noted:
 Coughing
Choking
 Neglect
Swallowing precautions: Pt needs to take small bites; after all meals & snacks, staff needs to check for pocketing of food
Bedside swallow results:
( Y)
Adaptive Equipment Needs:
Swallow study results: Y
Positioning needs:
Safety Needs Identified:
Findings: Bedside swallow exam attached. Requires ST is to teach patient safe swallowing techniques to
 risks of aspiration & to upgrade diet . MEM Requires to OT to teach scanning & compensatory
techniques for eating. LF
Why This Is Improved
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Need for interdisciplinary team clearly identified
FIM score supported
Indication that intervention is needed across the day
Supports need for skilled OT and ST
Improved Example of Team Assessment
Toileting
Date: 1/3/04
Initials:
MEM
FIM
4
Date: 1/3/04
Initials:
LP
FIM
4
Able to pull clothing down Mod A
Able to manage
closures Setup
Able to pull clothing up Mod A
Able to manage hygiene – Bladder Independent
Able to manage hygiene – Bowel – Mod A
Able to follow precautions (i.e., Hip) Supervision
LIMITATIONS
NOTED IN:
Balance
Coordination
Adaptive Equipment Needs: Grab bars at toilet
Safety
ROM
Sequencing
LE Strength
UE Strength
Problem
Solving
Raised toilet
Findings: Morbid obesity impairs toileting. Requires OT for neuro reed to relearn safe toileting. MEM
Requires PT training to  balance, coordination, and LE strength. LP
Why This Is Improved
• Supports impact of morbid obesity (comorbidity on
treatment)
• Supports need for interdisciplinary team
• Supports need for skilled OT and PT
Improved Example of Team Assessment
Summary Of Findings:
Overall clinical impression/rehab potential (qualified)
SW
SLP
Skilled SW is needed to teach patient and family strategies for coping with
disability. Pt. And family demonstrate readiness to participate in rehabilitation process
Initials: ___
Skilled ST is needed to teach patient compensatory strategies for safe swallowing.
Pt. voices desire to improve eating.
Initials: ___
Skilled OT is needed to teach balance, coordination, and safety techniques For
toileting, transfers, bathing, & dressing that will enable the patient to return home
without supervision.
Initials: ___
OT
Skilled PT is required for gait training to enable the patient to ambulate safely at
household distances. Pt needs to learn to use adaptive equipment, learn to incorporate
hip precautions into ambulation and transfers
Initials: ___
PT
Nursing
Rehab nursing is required to manage pain, reinforce learning of ADLs, manage
surgical wound site, reinforce nutritional education.
Initials:___
Why This Is Improved
• All disciplines document need for skilled level of intervention
• Supports need for interdisciplinary intervention
• OT’s identification of the need for toileting and bathing indicate the
need for equipment that is not usually in OP clinics for patient
training (bathtubs, commodes)
• Rehab nursing clearly documents their role in the POC.
Documenting on the Patient Care Plan
• The Patient Care Plan should include:
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Prioritized patient goals
Impairments, Activity, Participation
Planned Discharge Site
Interdisciplinary Long Term Goals
What disciplines will be involved in the care of the patient
Interventions
IAP Example
Admission
Discharge
Impairments
Osteoarthritis in knees,
hips, back, R shoulder
Osteoarthritis in knees, hips,
back, R shoulder
Activities
Impaired mobility, LB
dressing, bathing &
toileting
Improved to mod I in mobility,
bathing & dressing w/adaptive
equip.
Participation
Can’t shop for groceries,
Afraid to cook, can’t
perform job duties,
can’t play golf
Able to shop for basic food
items, can prepare simple
meal, will return to work 2
weeks post d/c, return to golf 6
mo post d/c
Documenting Progress
• At least weekly, a summary of the patient’s progress should be
documented.
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Document progress toward goals
Detail barriers to achievement of goals
Describe changes to the plan of care as appropriate
Describe patient’s response to treatment
State the justification for continued stay on the rehab unit
Poor Documentation of Progress
Occupational Therapy
Weekly
D/C
Summary:
Pt mod A with bathing, UB & LB dressing; strength & endurance improved. Toileting
@ Sup. 3 of 4 goals met. POC to co ntinue.
_____P.C. Perfect OTR_______3/15/04__________
Signature
Date
Why This Is Poor
• Note does not reflect skilled intervention
• Note does not address the reasons that skilled services are
needed – the teaching of hip precautions, the teaching of
adaptive equipment usage
• Note does not document the need for continued skilled therapy
Improved Example of Progress
Occupational Therapy
Weekly
D/C
Summary:
Pt taught hip precautions during bathing, toileting, and lower body dressing with fair
return demonstrations. Pt educated in use of reacher for functional activities, now
independent with use. Pt morning ADL routine has improved speed. Pt continues to
need skilled OT services to become independent with hip precautions in ADLs and
to continue to reduce the amount of time required for morning ADLs.
_____P.C. Perfect OTR_______3/15/04__________
Signature
Date
Why This Is Improved
• Details the skilled intervention provided by the therapist – i.e.,
“taught”, “educated”
• Addresses weekly short term functional goals
• Summarizes daily treatment interventions
• Documents need for continued skilled intervention
Daily Documentation of Medical Necessity
• Daily documentation should show skilled need in:
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Weekly short term goals
Total units of therapy
Treatment/training
Daily comments
Poor Documentation of Goals
Weekly short-term goals:
1. Pt will be indep. in grooming.
2. Pt will dress UB & LB with supervision.
3. Pt will bath with min assist.
4. _______________________________________________
5. _______________________________________________
Met
Not Met
Cont.
Why Is This Poor
• Typical pt. w/hip replacement would not need skilled
therapy to relearn basic ADLs
Improved Example of Goals
Weekly short-term goals:
1. Pt will adhere to hip precautions in toileting and lower
body dressing independently
2. Pt will use reacher in dressing and housekeeping tasks
to maintain hip precautions independently
3. Pt will bathe lower body safely, maintaining balance and
hip precautions at mod I.
4. Pt will complete morning ADL routine within 45 min at
mod I
5. _______________________________________________
Met
Not Met
Cont.
Why This Is Improved
• Details the need for OT in ADLS
• Documents specific area requiring learning – it is not that
patient needs to relearn how to put on clothes, bathe, etc.,
but that patient needs to learn how to use his hip
precautions in each of these basic life activities
• Puts ADLs into functional routine that has a meaningful
measure to patient and family
What Constitutes a Skilled Service
• Knowledge and training of a professional is necessary
• Need should be indicated in initial evaluation
• Evidence that skilled services were performed should be
reflected in notes
What Constitutes a Skilled Service
• Services must be of such a level of complexity and sophistication
or the condition of the patient must be such that the services
required can only be safely and effectively performed by
qualified nurses and therapists.
• Skilled services can be:
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Diagnostic and assessment
Designing treatment
Establishment of compensatory skills
Providing patient instruction
Reevaluations
Skilled versus Non-Skilled
Nonskilled
Skilled
Observed patient trying to
get out of bed. Pt unable
to come to sitting without
help.
Training provided to facilitate
independence in bed mobility. Tactile
and verbal cuing provided to produce
knee flexion and arm extension and
push.
Pt expression - 2 with
nurses.
Pt. taught to use call light and respond
“bathroom”. Pt able to perform
sequence of pushing call light and
responding to nurse 4/5.
Pt – UB Dressing 4
Pt. taught strategies for compensation of
left visual neglect to facilitate
independence in dressing. Min assist
required for buttoning shirt.
Denials
• Why do payers tell us they deny claims?
 Patient does not meet eligibility criteria
 Services are not skilled
 Services are not necessary for patient’s diagnosis, medical condition,
or no assessed need
Denials
• How can we avoid denials?
 Document interventions clearly and precisely
 Use active, descriptive verbs
Terms
Terms To Avoid
Terms That Connote Skilled Services
Ambulate
Gait training
Monitor
Assess
Observe
Evaluate
Tires easily
Required rest periods due to…..
Encourage
Instruct/educate
Discuss
Teach
Drills
Tasks
Little change
Continues to require
Pt performed
Continues to progress
Supervised
Analyze
Design
Questions?
Next call - February 6 at 1:00 EST
Lisa Bazemore, MBA, MS, CCC-SLP
Lbazemore@erehabdata.com
(202) 588-1766