This and That

Ask a Therapist: Tips on Clinical Documentation

 

Paragon Rehabilitation is committed to clinical excellence. Every year our therapists demonstrate outstanding clinical excellence based on completed, timely documentation, eDoc Audit scores consistently exceed expectations, focused clinical programs and response to clinical support. Our commitment to compliance is one of the components that makes Paragon stand above our competitors, which is why we’ve asked our 2017 Clinical Program of the Year Award Winners, Bheng Posada and Brock Best to share their best tips on clinical documentation.

As a Registered Therapist:

  • Collaborate with your PTAs/COTAs regarding treatment goals from the POC, treatment plans, and daily notes.  Co-sign daily notes, as required by State Practice Act.
  • Double check that your documentation reflects the skilled nature of the therapeutic interventions and demonstrates medical necessity.
  • Ensure daily notes clearly indicate the resident’s response to treatment, the purpose of each activity or task and its relationship to function and goals, and the skilled interventions of the therapist/assistant for each billed CPT code.
  • Goal Writing:  Develop long term goals first then work backward from those to identify functional short-term goals.
  • Develop measurable short-term goals that may be obtained within a single reporting period.
  • Ensure goals are appropriate for resident’s anticipated discharge location and place with high importance on home evaluations/discharge location visits as part of treatment. Include all recommendations for safe return to discharge environment on subsequent documentation.
  • Document ongoing discharge planning with resident and family – utilize interdisciplinary team approach to identify and plan appropriate discharge location.
  • If family members and/or caregivers are present during treatment, provide direct model and training of skilled techniques and document return demonstration percentage and cueing levels to promote carryover.

As an Assistant:

  • Ensure a clear understanding of the plan of care by reviewing documentation and asking questions as needed regarding the treatment plan.
  • Frequently coordinate with the therapists to provide updates on progress and review treatment techniques to ensure quality care and continuity of treatment.
  • Ensure daily notes clearly indicate the resident response to treatment, the purpose of each activity or task and its relationship to function and goals, and the skilled interventions of the therapist/assistant for each billed CPT code.
  • If family members and/or caregivers are present during treatment, provide direct model and training of skilled techniques and document return demonstration percentage and cueing levels to promote carryover.

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