Documentation Expectations

What am I Supposed to Document? Once the process of counting is mastered, the issue of documentation expectations remains. There is a terminology challenge that cannot be overlooked. We are required to complete “reassessments” not “re-evaluations.” There is a very real and significant difference between the two. Re-evaluations focus on collecting information on the patient. Functional ability, strength, range of motion, and self-care ability are a few examples and are used to provide an updated picture of the patient when compared to the previous evaluation. Reassessments focus on the plan of care utilizing objective information about the patient to support that the course of care in effective. Looking at the language of the Therapy Clarifications in the PPS 2011 Final Rule, reassessments provide the opportunity to review the care plan and determine if there needs to be any changes to the interventions or goals or if the current treatment plan should continue as originally planned. Key elements of the reassessment are as follows:
  • Objective Information. Clinical information about the patient that shows the impact of therapy to this point. Can use formal tests and/or standardized assessments such as range of motion measurements and manual muscle testing.
  • “Effectiveness” of Therapy. Speaks to the role of the therapist in providing specific interventions that have or will have meaningful impact on the patient’s quality of life. There is NO requirement for progress at the time of reassessment only the opportunity to show progress to this point or support why it is reasonable to expect it with additional therapy care.
  • “Clinically Supported Statement.” This is NOT a canned statement that is used for all patients. It is narrative information that connects the objective findings to the provided interventions.
  • Plan to Continue or Discontinue. Decision must be based on the ability to confirm the medical necessity of therapy.
Some are recommending the completion of the same evaluation form used during the initial therapy visit. It is an option to consider, but it is not a requirement. There is no Medicare recommended format for documentation content and no “official” form that must be used. It is a good idea to build triggers into a note to ensure that the necessary content pieces are covered, but it is critical to create focused meaningful content not just more documentation. Although therapy reassessments are now mandatory, it should be seen as a positive opportunity to highlight the benefits of skilled therapy interventions and reinforce the importance of each discipline as members of the interdisciplinary team.
Cindy Krafft, September 2013