The new year is a great time to focus on improving outpatient therapy documentation. Through a series of complimentary webinars with Clinicient on functional limitation reporting, manual medical review and all things Medicare we presented documentation best practices. Therapy documentation top 5 best practices grew out of what we learned from the first wave of manual medical review of therapy over the $3700 threshold in the 4th quarter of 2012. We heard from Medicare medical review departments (3 MACs) therapy documentation mistakes.
Taking this information as well as therapy documentation requirements posted in the Medicare Benefits Policy Manual (Chapter 15 , beginning at Section 220), Jerry Henderson and I came up with a quick graph of Therapy Documentation Top 5 Best Practices.
Therapy Documentation Best PracticesTop 5 best practices for therapy documentation and how to include in the evaluation, plan of care, daily notes, progress reports and discharge reports
|1.||Test, measure and document functional scores, performance tests and clinical findings||Initial Evaluation|
|2.||Relate clinical findings and short term goals to functional deficits and long term goals||Initial Evaluation &|
Plan of Care
|3.||Skilled intervention demonstrated through ongoing patient assessment, exercise, functional progression, and techniques and parameters utilized||Daily Notes|
|4.||Serially track and update important clinical and functional findings related to goals||Progress Report|
|5.||Entire episode of care summarized to include , patient progress, goal achievement, and reason for discharge||Discharge Summary|
As the new year gets started at your clinic, take the opportunity to elevate therapy documentation in all required elements of the initial evaluation, plan of care, daily notes, progress reports and discharge summaries. Better yet, plan an internal “round robin” chart review during a lunch and learn and see where therapy documentation top 5 best practices are already in place, and call out those documents in a teachable moment.