Use skilled terminology in your notes or assessments that justify the need for or the continuation of skilled services. Documentation should focus on skilled training, not the repetitive completion of task that can be completed by a CNA. For example, an OT documents ADLs daily; this is not a skilled activity.
Focus on the training of techniques, compensatory strategies, correcting implements, etc. For example, do not use ambulation in skilled documentation; refer to gait training and specify deviations and deficits as well as the level of assist, distance, and device use. Be specific and use skilled terminology to describe the service:
- Progressive therapeutic exercise versus repetitious exercise
- Observation and correction of techniques
- Gait training versus ambulation
- Neuromuscular facilitation
Other phrases that justify skilled services are:
- High risk for
- Skilled assessment
- Treatment is reasonable and necessary
- Potential for recurrence
- There is a likelihood of change
- The treatment regime is not stabilized
- Observation and assessment for potential complications
- Plan of care is being monitored to promote recovery and ensure medical safety
Skilled vs. Routine Services
The following table compares skilled and non-skilled or routine therapy services. Review each and note the differences between skilled and routine therapy services. Think of routine services as being custodial and not requiring the skills of a therapist to perform them.
- Gait training addressing specific gait abnormalities with anticipated improvement
- Therapeutic exercise that leads to an improvement in functional independence and/or quality of movement
- Design a treatment plan tailored to the strengths and weaknesses of an individual patient
- Caregiver training education that will support therapeutic interventions
- Development and training of a maintenance program
- Wellness programs intended to promote overall well being and fitness.
- Monitoring safety and task completion without staff training or anticipation for improvement.
- Ongoing visits for splint application without changes in ROM or problems with splint.
- Ambulation only with no anticipated improvement.
- Practice with an augmentive communication device.
- Assistance in dressing, eating, and going to the toilet.
- General supervision of exercises that have been taught to the patient and the performance of repetitious exercises.
Poor selection of terminology does not support medical necessity or the need for skilled therapy services. For example, do not use negative words regarding patient behavior such as resistive, unmotivated, uncooperative, noncompliant, or poor participation. Other examples of phrases that do not support skilled services are:
- No changes/unchanged/status quo
- Unable to tolerate therapy
- Poor potential to meet goals
Examples of Skilled then Non-Skilled Clinical Documentation
Pt able to feed self with min assist each meal using dominant RUE, given decreased environmental distraction, set up of tray, and occasional VC to sustain attention. VS Pt feeding self with min assist.
Pt hemiplegic LUE displays flexor synergy of shldr horizontal adductors and elbow flexor that enables pt to wipe tabletop (gravity assisted positions). VS Pt left arm improving in strength.
Pt's cognition currently scores ACL 3.2, GDS 6, which indicate loss of functional problem solving and sequencing. VS Pt's cognition is poor.
Pt's RUE ROM has improved to allow donning of shirt but lacks finger dexterity and strength enough to maneuver buttons. VS Pt unable to dress self.
Pt receiving e-stim - MFAC x 20 min, surrounding L shldr with report of 4/10 pain scale allowing pt to don/doff pants and shirt with SBA. VS Pt receiving e-stim to shldr with decrease in pain.
Pt completed 20 reps of shoulder/elbow flexion with 2# weight to strengthen deltoids and biceps in preparation for UE dressing. VS Pt performing wand exercises to BUE, 20 reps with 2# weight.
Modification of splint allows 4 hrs of wearing schedule without signs and symptoms of skin breakdown noted. ROM of wrist improved to 45 degree flexion, which allows donning of pants. VS Pt wearing splint for 4 hrs without difficulty.
Pt exhibits limited carryover of long handled sponge due to impaired cognition (ACL 3.8) and requires set up, initial VC and addition of strong figure group contrast on handle (red electrical tape). VS Pt appears unmotivated to use long handled sponge.
Establishing Treatment Priorities
1. Audience: Therapists
2. Basic Skills
2.1 Understand basic anatomy of the body parts you will be helping to rehabilitate.
2.2 Understand and be able to indentify the impairments that lead to decreased function.
2.3 Apply knowledge of the discipline specific interventions based on the impairments identified.
2.4 Identify patient's basic functional needs required for anticipated discharge environment.
2.5 Identify which basic needs are most desired by the patient.
2.6 Determine which functional skills make overall care easier.
2.7 Identify which functional skills are prerequisites to other skills.
3. Advanced Skills
3.1 Identify safety considerations for all skills.
3.2 Identify which safety issues will need to be prioritized due to high risk (i.e., the risk of aspiration due to swallowing difficulty may supercede the patient's desire to work on walking).
3.3 Based on patient's prior performance, which skill is likely to be most successful for the patient.
3.4 Based on experience with other patients, which skill is this type of patient likely to succeed at first.
4.1 Confirmation by the team.
4.2 Confirmation by the outcome.
4.3 Confirmation by weekly progress notes which demonstrates increasing functional competence, with later skills building on earlier skills.
Geriatric Treatment Planning
1. Audience: Therapy staff, nursing, discharge planners, social workers.
2. Basic Skills
2.1 Understand impact of co-morbidities on patient function.
2.2 Assess needs based on anticipated discharge setting.
2.3 Assess patient's/family's overall needs and priorities.
2.4 Apply knowledge of the normal aging process, including decreased balance, depression, cognitive impairments, decreased muscle mass and decreased strength, to differentiate between normal aging and disease processes.
2.5 Apply knowledge of the complications commonly found in the older adult: dehydration, isolation, vitamin deficiencies, poor nutrition, decreased sensation, decreased flexibility, and medical decline.
2.6 Develop realistic goals, considering that timelines may be longer given the increased healing time needed for the elderly.
2.7 Select appropriate mode of interventions/intensities of therapy: consider lower endurance, less strength, decreased learning speed, diminished cognition, and compounding medical diagnoses, which may necessitate increased or decreased intensity for optimal outcomes.
2.8 Understand family/psychological concerns regarding aging and loss.
2.9 Assess risks (falls, weight loss, skin integrity, safety).
2.10 Provide patient, family and/or caregiver education to ensure carryover of gains made in therapy.
3. Advanced Skills
3.1 Consider the functional effects of the patient's medications, including the purpose and action of the drugs, as well as potential side effects and drug interactions.
3.2 Assess home safety and function, and develop modifications/adaptations to accomodate the change of normal aging, as well as disease-specific disabilities.
3.3 Educate the patient/family about community resources to support the elderly and/or related to specific diseases.
3.4 Understand family/caregiver's ability to follow through with care.
3.5 Consider time constraints in the SNF and whether or not CNAs can realistically follow through insupporting the patient's goals.
4. Assessing Effectiveness
4.1 Positive patient outcomes.
4.2 Customer satisfaction.
4.3 Lack of re-admit or regression.
4.4 Positive feedback from nursing/CNA staff.
4.5 Referral from same MD.
4.6 Expectations/goals met.