maintenance physical therapy documentation examples

Progress patient with strengthening exercises to increase quad activation and trial straight cane at parallel bars. The clinician handles visual, verbal or manual contact with the patient, and is responsible for documentation of billable time and medical necessity. Gait: Patient ambulates on level surfaces with FWW. Facilitated Balance: Rhomberg stance: positive; Single-leg stance: unable on Left, for up to 3 seconds on Right. 2023 Harmony Healthcare International, Inc.. All Rights Reserved. This initial blog will focus on mode of therapy provisions under this new payment model and address the documentation guidelines regarding group and concurrent therapy. Services that do not require the performance or supervision of a therapist are not considered skilled even if they are performed by a therapist. Each is allowable and reimbursable by Medicare. 8. The emphasis is placed on prior level of function and typically has a higher intensity and shorter duration. Maintenance Therapy, Im impressed with their HIPAA compliance, PHI protection and data breach prevention protocols. Couldnt have asked for more. 2. Instructed SLR lag: 1 degree, Rhomberg test: negative; sensation: intact; incision: closed, clean, and healing well. Supervising Documentation should demonstrate medical necessity, progress, and skilled care, etc. For more information about the ONC, please visit:http://www.healthit.gov/newsroom/about-onc. Initial Patient/Client Management A. Within 2 weeks, the patient will report a 20% reduction in knee pain at night in order to facilitate their ability to fall asleep. Patient instructed in 5 minutes of level 1 resistance then graded to level 2 resistance for 5 minutes and finally level 3 resistance for the remainder of task. j The patient will perform oral motor exercises to maintain functional oral motor strength for speech and swallowing capabilities daily with speech therapy cuing and supervision. Continued use of FWW recommended. 7. These Therapy Documentation Templates will help you effortlessly write physical therapy assessment phrases that are as skilled as the treatments you provide in the clinic. Able to mimic after visual demo with good execution. R 7/40.2.1/General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy . Learn more about this, and other related topics in the course Audit Proof Your Skilled Therapy Documentation. Take personal notes. No matter how many years of experience you have in this field, you need to show your distinct skill in your documentation. Medicare does indeed cover services to maintain or manage a beneficiary's current condition when no functional improvement is possible. Physical Therapist: _______________________ Date:_________ Time: _________, Physician Signature: ______________________ Date: ________ Time: _________, Patient stated I am better able to sleep at night with less throbbing in my knee. Examples of skilled maintenance services include: Establishment of a maintenance plan of care. Patient with max cues for posture to reduce trunk sway with standing tasks. Patient denied pain, just complained of overall weakness. Patient reported functional progress with opening jars in prep for feeding and grooming tasks. The Jimmo Settlement confirms that Medicare coverage is available for skilled nursing and therapy that is needed to maintain a persons condition or slow deterioration, for nursing home, home health, and outpatient therapy. Discharge from PT x Continue PT 2 x per week for 3 weeks. Patient also instructed in pursed lipped breathing to reduce complaints of shortness of breath and elicit usage of energy conservation techniques. When treating patients, use shorthand to take quick personal notes about your interactions and observations. Physical therapy forms should address several important questions to establish medical necessity. 2021 PTProgress - Our content does not constitute medical, financial, or legal consultation. By using this site, you are consenting to our use of cookies. This means that your documentation should: Explain your reasons for choosing group therapy, including in each patient's plan of care explicit justification for choosing group therapy as an adjunct to individual or concurrent therapy. endobj <>/Metadata 2040 0 R/ViewerPreferences 2041 0 R>> Save my name, email, and website in this browser for the next time I comment. LEFS: 10% perceived impairment. Patient arrived at OT for engagement in incontinence management including PMEs to reduce urinary urgency. See a certified medical, financial, or legal professional for advice. Words and phrases that therapists and assistants should avoid because they often demonstrate lack of skilled care include: Tolerated well In addition to supervising the services provided by the PTA, the qualified therapist is still responsible for the initial assessment, plan of care, maintenance program development and modifications, and reassessment every 30 days. He demonstrates overall improved strength and stability with functional activities and with gait form. CMS looks favorably on the use of CEHRT since HHS is trying to encourage the adoption of CEHRT amongs providers nationwide as part of a long term push towards electronic documentation and interoperability between EMR systems. The rationale for clinical decisions must be documented at regular intervals. Treatment included conversational practice. collection of physiologic data (for example, ECG, blood pressure, glucose monitoring . OT individualized and instructed patient in AROM exercises to max patient range in pain free zone as follows: IR/ER, abd/add 110, extension with 3 second hold. The conscious use of skill especially in the production of works. If you didnt provide any cueing, recommendation, or therapeutic insight or intervention, what did you do?? PT graded task to perform in standing side crunches with 5# weight x 10 each side with CGA at times for balance. Each requires the same burden of proof of skill. A skilled PT is required to address these key impairments and to provide and progress with an appropriate home exercise program. Physical Therapy Documentation Examples and Documentation Best Practices Physical Therapy Documentation Examples (Downloadable) and Best Practices with Physical Therapy Forms At In Touch EMR, we get daily calls from clinicians, owners and students asking us for physical therapy documentation examples that qualify as 'defensible documentation'. The patient lives with family who are able to assist driving him to appointments until cleared by a physician to drive. 17. PT facilitated patient to complete standing Achilles stretch and seated quad and HS stretch, 3x 30sec each with mod cues for technique and to complete in pain free range for improved gait pattern and maximize ROM. Within 2 weeks, the patient will demonstrate improved quad strength and motor control as noted by ability to perform SLR without lag in order to progress into advanced ther ex. I had previously tried more complicated systems that made me exhausted at the end of the day. Click Add to Cart at the top to purchase the entire bundle at a 30% discount! CC: Increased pain and stiffness in left knee prevents him from sleeping well at night and limits his ability to walk or stand for more than 10 minutes. Problem Summary: Increased pain at left knee, decreased ROM of left knee, decreased strength of L LE, balance deficits in standing, difficulty with weight bearing activities, altered posture, lack of home exercise program, impaired gait form and use of assistive device. 15. He demonstrates gait deviations that include the following: increased lateral trunk lean to the left with stance phase, decreased push off bilaterally, poor knee flexion with swing, decreased hip extension with push off and impaired ability to turn corners due to unsteadiness attributed to unnatural use of walker. hb```B@((jHBSCM7$::#)V @, Examples include strength, balance, respiration, posture, balance, and pain Skilled physical therapy is often beneficial to address specific and acute problems, and the traditional model is for PT to make focused goals towards improvement, with subsequent discharge when the goal is met or the client's progress plateaus. Jimmo, Data collection is the foundation for monitoring progress, but, in itself is a daunting task. With our comprehensive collection of high-quality examples, you'll be able to improve your documentation skills and increase productivity. (Skilled terminology is highlighted in red.) Required max verbal cues, tactile cues and visual demo to reduce compensatory strategies. Task adapted and modified in response to patients complaints, however, patient with increased pain to 8/10 with stretching. These sample phrases may be used in the objective (observational) or assessment (interpretation and judgment) sections of your therapy documentation. Steri strips are present along a 20 cm incision. to develop a key of frequently used abbreviations on most documentation forms or request therapists to completely spell any word the first time it is written with the shortened form in parentheses (e.g. lets get skilled. Patient arrived at therapy with 3/10 L hip pain. Fear makes us focus on quantity as opposed to quality of documentation. , Educated the patient on proper performance of sit-to-stand, emphasizing body mechanics and proper alignment of knees.. maintenance therapy under the Medicare home health benefit in accordance with individual state practice . The front desk automation (certification alerts, patient portal, birthday reminders, e-newsletters) and clinician automation (progress note and reevaluation countdown, autotext technology, flowsheet templates, tasks and messages) are sufficient to set them apart. If they are, are the skills of a licensed therapist needed? Unskilled treatment note: Pt continues to present with unintelligible speech. What is the patients point of view? Extensibility: Tightness noted in the following muscle groups: bilateral hamstring, quadriceps, and gastroc/soleus. The second part of this series will then provide you with actual documentation examples that may not support group and concurrent therapy as skilled and reasonable. Advised patient on safe use of walker to encourage proximity to device. Patient trained in the following exercises using moderately resistive putty in order to increase gross grasp and various pinches: gross grasp, opposition, abd/add, tip pinch. Some examples listed on this site are: Instruct patient and caregiver in use and care of communication system. All handwritten entries shall be made in ink and will include original signatures. Educated on individualized HEP program, reviewed and facilitated exercises with min vc to initiate. These dynamic activities must be part of an active written plan of care and be directed at a specific outcome. Words/phrases that help document skilled care are listed below. Overall, patient completed x 15 minutes with PT directing patient with interval training of grading resistance 1-2 minutes. 774 0 obj <>/Filter/FlateDecode/ID[]/Index[759 26]/Info 758 0 R/Length 77/Prev 74802/Root 760 0 R/Size 785/Type/XRef/W[1 2 1]>>stream The fear is What if I dont document correctly?. The exercises that are performed will depend on each patient's unique conditions, but might include: Swimming Walking Aerobics Jogging Cycling Rowing Squatting Stretching Stretching helps to maintain flexibility and mobility. Support is always there when we need it, options to customize options to match our workflow are endless, clinicians find it simple and easy to use, front desk and billing love the integration between documentation and claims and compliance is built-in. No assistive device used. Electronic entries are made with appropriate security and confidentiality provisions. 10 minutes Cold Pack (97010): Left knee patient in supine with knee supported by bolster for comfort following exercises and treatment. Patient required standing rest breaks in between each set and 2 seated rest breaks overall. Tim Fraticelli is a Physical Therapist, Certified Financial Planner and founder of PTProgress.com. While there's no special code or modifier to indicate whether a therapy service is considered maintenance care or rehabilitative care, your documentation must clearly state when services are intended to maintain the patient's function. Examples include: Self-referral/direct access Request for consultation from another practitioner Documentation should include indication of no shows and cancellations. The patient will maintain tolerance for ___ splint as applied by occupational therapy and periodic skin assessment for s/s of redness. This set includes the following: Physical therapy documentation should justify medical necessity. PT ceased task to reduce and direct program toward pain management. Patient is at risk for Patient arrived at therapy with RLE weakness and decreased heel strike during assessment of gait. Was skilled therapy needed? 6. In seated position, patient was instructed in LLE strengthening exercises to decrease left foot drop during ambulation prior to functional mobility task. It is a summary of all the physical therapy forms you need in your practice. Charting errors should be corrected by drawing a single line through the error and initialing and dating the chart or through the appropriate mechanism for electronic documentation that clearly indicates that a change was made without deletion of the original record. Verbal cues were provided to improve postural alignment and engage in pursed lipped breathing to maximize functional tolerance. O2 monitored pre, during and post exercise with O2 levels > 95% to ensure positive response and reduce risk of desaturation. This task is useful for meeting goals of independent dressing., The patient demonstrates poor scapular upward rotation with reaching. Repetitive language (not individualizing sessions/copy feature) Mild to moderate edema noted at knee with pitting noted as 1+ at tibia. 1 0 obj What are the skilled areas that require maintenance therapy? Member Login. In Touch EMR is one of the only EMR vendors in the rehabilitation space to pass all the 2014 Edition EHR Certification criteria required to satisfy the Base EHR Definition as stated by the Office of the National Coordinator for Health Information Technology, as listed here: http://www.healthit.gov/sites/default/files/pdf/BaseEHR_8-18-12_Final.pdf. The most common example of the difference between an ownership change and a CHOW involves stock transfers. You may not have the time to read dozens of documentation examples, so I have included below an example of 4 types of notes commonly used in physical therapy. Patient arrives to therapy with complaints of sciatica. (Skilled terminology is highlighted in red.). Most of the difficulty in writing defensible documentation lies in the assessment section. Physical therapy documentation is an important tool for recording therapy treatments and tracking a patients progress. A therapists skills may be documented by descriptions of skilled treatment, changes made to treatment due to an assessment of the patients needs on a particular treatment day or changes due to progress the therapist judged sufficient to modify treatment toward the next more complex or difficult task. With my 60+ examples of assessment phrases in real-life scenarios, youll have access to a comprehensive resource that will improve the efficiency and quality of your writing. 4. I have created a handout that you can provide to your PT, which details coverage, documentation, Medicare . N - Narrate your client's accomplishments. The patient has achieved 100% of short-term and long-term goals. Send us a note. Contact Us, 10 ways to speed up physical therapy documentation, our company / founders have been mentioned on CNN, Forbes, Huffington Post, Amazon, received the prestigious ONC certification, 2015 and 2016 PQRS registry designation, integrated with Microsofts cutting edge patient portal technology, http://www.healthit.gov/newsroom/about-onc. Pain Scale / location / behavior: Patient presents with pain along the left joint line lateral to the left patella. I am a physical therapist in the homecare setting. PHd$2 +4^{D=fO:%hWVuOq~4ssatP6 A well defined workflow for the front desk, clinicians, billers and coders makes this a one-stop shop for quick, compliant documentation and flawless billing. Here are some additional guidelines for defensible documentation: In Touch EMR is a fully integrated scheduling, documentation and billing software for physical therapy practices. The patient will identify potential fall hazards in path with potential loss of balance 80% accuracy through daily skilled intervention with physical therapy. A physical furthermore occupational therapist providing you at evidence-based treatments both samples starting record into show your skill. He loves to teach PTs and OTs ways to save time and money in and out of the clinic, especially when it comes to documentation or continuing education. The end point of therapy also needs to be clearly defined. 443-850- 0421, Pt continues to disregard side rails (whatever theyre being non compliant with, cane, crutches etc. Email:Help@HomeCEU.com Patient completed x 15 minutes with PT facilitating interval training of varying resistance 1-2 minutes. Examples, based on the patient's need, may include: mobility status (transfers, bed mobility, gait, etc. Once the treatment has begun, the therapist must monitor the treatment regularly. See more onMedicare payment for home health. Assessment Statement: Patient presents with signs and symptoms consistent with diagnosis of L knee OA, s/p 1 week post operative L TKA. The patient demonstrates lack of quad muscle recruitment during knee extension. No signs of infection noted. xn@-regm)Dii(zHMQ}g m(]9s|!|!PJIFx.{ l2;ga! For your convenience, we are, for a limited time, allowing you to download the In Touch EMR physical therapy documentation examples set. endstream Able to complete 15 of each exercise prior to modifying task secondary to fatigue. What is the illness? Physical Therapy Evaluation Example Evaluation Date: 01/06/2016 Treatment Time: 09:00 to 10:00 Patient Name: Henry Smith DOB: 3/22/1957 Physician: Dr. James Anderson Medical Diagnosis: M17.12 Left knee OA s/p TKA 12/28/15 Follow him on YouTube for weekly videos on ways to improve your financial health. PT provided cues to maintain hips in neutral vs. add during task, cues to maintain SPM >55, cues for pursed lipped breathing. The patient will maintain _____ degrees AAROM UE to reduce risk of fixed bony contracture. Physical Therapy Approvals for CE Courses, Speech-Language Pathology (SLP) Approvals, Speech Language Pathology CE Requirements, SLP Strategies for Building a SNF Caseload, Occupational Therapy Continuing Education, Nutrition & Registered Dietitian Continuing Education. PT instructed patient in the following exercises to improve functional ROM to facilitate improved gait pattern and reduce falls risk with standing tasks. step to] technique with physical therapy. 3. 784 0 obj <>stream Patient denied shortness of breath and indicated just right challenge. hbspt.cta._relativeUrls=true;hbspt.cta.load(56632, '60ecaa68-9b11-4d0d-a0d6-4a6af6371f99', {"useNewLoader":"true","region":"na1"}); Massachusetts Finally Changes from MMQ to MDS for Medicaid Payments, Internet Quality Improvement and Evaluation System (iQIES), Harmony Healthcare International, Inc. (HHI). %%EOF DO NOT assume Medicare is unavailable based on: Rules of Thumb, Diagnosis, Wants or Needs. Patient was able to execute with no reported increase in pain in prep for gait training. Pain and symptoms, use of narcotics, anti- anxiety treatment, anticipating the effects and skilled end of life. Here are the top ten things you should know about providing Maintenance therapy. Patient directed in NuStep training to increase biofeedback to BLE, mimic reciprocal pattern and increase overall BLE strength to decrease abnormal gait pattern. Pt instructed in posterior pelvic tilts 310 with 3 sec hold. Several nonfederal payers also have clarified their policies regarding the improvement standard and skilled maintenance coverage. This may mean compacting the information that the patient has given you to get the information across succinctly. Analyze documentation examples to set realistic functional goals, establish treatment effectiveness, and correctly modify selected interventions. Our focus was on glute activation prior to hip extension., Abdominal contraction prior to squatting (timing), A change in sequencing of abdominal recruitment prior to squatting improved lumbar posture and reduced pain., The patient was challenged in achieving proper squat technique due to balance deficits. hbspt.cta._relativeUrls=true;hbspt.cta.load(56632, '60ecaa68-9b11-4d0d-a0d6-4a6af6371f99', {"useNewLoader":"true","region":"na1"}); Massachusetts Finally Changes from MMQ to MDS for Medicaid Payments, Internet Quality Improvement and Evaluation System (iQIES), Harmony Healthcare International, Inc. (HHI).

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