maintenance physical therapy documentation examples

Documentation should include the referral mechanism by which physical therapy services are initiated. The patient will maintain the ability to perform toilet transfers at moderate assist level to prevent deterioration due to Parkinsons disease with significant intention tremors. 6 0 obj Patient instructed in L wrist flex/ext, radial/ulnar deviation, opposition, finger abd/add, MCP flex/ext, PIP flex/ext 210 with therapeutic rest as needed. This is achieved with a combination of customized physical therapy documentation examples, specific to the patient and your treatment philosophy, regular tests, standardized tools, subjective feedback and various measures. Q Can you please give some examples of documentation that shows the unique skill of a therapist in a maintenance scenario? See privacy policy and disclosure page for details. The information in this handbook is intended for therapy services for clients of all ages. 10 minutes Manual Therapy (97140): Seated tibiofemoral distraction grade 2 mobilization for pain relief, supine patellar mobilizations in superior/inferior direction: grade 2 x 4 minutes, mobilization with movement of patella with SAQ x 3 minutes. Patient presents to skilled PT s/p fall in patients bathroom resulting in R sided hip pain and overall weakness. Treatment Plan Progress: Each progress note should mention whether a client's treatment plan objectives are being met. Disclosure: This post may contain affiliate links, meaning I may get a commission if you decide to make a purchase through my links, at no cost to you. All In Touch EMR customers get unlimited support via phone, email and live chat. Adapted Follow these steps to produce thorough, effective SOAP notes for physical therapy: 1. , Educated the patient on proper performance of sit-to-stand, emphasizing body mechanics and proper alignment of knees.. The patient has been educated in the evaluation findings, prognosis, and plan of care, and is in agreement and willing to participate in therapy. Show me the subjective intake of the initial evaluation. In Touch EMR is on the Certified Health IT Product List (CHPL) website. Knowing appropriate Physical Therapy documentation phrases can help explain your intended treatment and justify more complex treatments such as neuromuscular re-education, therapeutic activity, and self-care. Patient instructed in GE towel slides flexion/extension and horiz add/abd on table top 310 with assistance of LUE as needed; however, OT facilitated constraint therapy to increase RUE movement. O2 and RR levels were closely monitored throughout exercise with no abnormal response from baseline when patient was assessed. In side lying, patient instructed in 310 R hip abduction using 2.5# weights, prone L hip extension, supine single leg raise to patients max tolerance. The handbook provides information about Texas Medicaid's benefits, policies, and procedures applicable to these therapies. 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. WHY DO WE DOCUMENT CLINICAL CARE? 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. Rehabilitation therapy enhances or restores an individual's ability to return to their prior level of function and health. In Touch EMR and In Touch Biller Pro represent a united and unified package that helps the private practice clinician govern a practice. When the clinician combines clinical judgment with subjective findings reported by the patient and caregiver considerations, a precise clinical picture emerges. 16. The following examples are sample physical therapy documentation phrases to help you appropriately identify the skills involved in performing each treatment (in bold). 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). Words and phrases that therapists and assistants should avoid because they often demonstrate lack of skilled care include: Tolerated well Tandem stance: requires UE support with balance loss upon perturbation. Phone:1800.55.4CEUS (2387)Privacy Policy. This evaluation is of moderate complexity due to the changing nature of the patients presentation as well as the comorbidities and medical factors included in this evaluation. Examples include: Home program. To help therapists and assistants improve their documentation, the following are examples of documentation that clearly demonstrates the skilled nature of therapeutic exercise. 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. Physical therapy documentation is an important tool for recording therapy treatments and tracking a patients progress. We have also taken the time tocompare medical billing softwareand created a comprehensive resource for you. This may mean compacting the information that the patient has given you to get the information across succinctly. Make sure your documentation shows it but in less time and with better clarity! 5 0 obj Patient arrived at PT with 4/10 R hip pain. When the treatment is expected to result in significant therapeutic improvement over a clearly defined period of time. Patient used FWW to ambulate into clinic with equal step length noted. DO NOT assume Medicare is unavailable based on: Rules of Thumb, Diagnosis, Wants or Needs. Patient needed stimulation . See privacy policy and disclosure page for details. 7. You can download these examples in PDF format here (click on image). 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. 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. 3 0 obj Lack of proper vehicular maintenance. This section will address the nuances of documentation, billing, and reimbursement issues in the context of documentation, specific to pediatric physical therapy. Treatment to Include: AROM/AAROM/PROM, balance and proprioception training, strengthening exercises, HEP, mobilization, posture/body mechanic training, neuromuscular re-education, and ice pack to LLE. In supine, patient instructed in R hip abd/add, flex/ext, bridging 310 with tactile guiding due to weakness. It can also be the cause of major headaches, rushed lunch hours, and excessive typing throughout the day. Each is allowable and reimbursable by Medicare. PT educated patient in B hand strengthening exercises post estim to improve overall grip/pincer grasps. Master bedroom/bathroom is on the main floor. For patients with chronic or degenerative conditions, evaluate patients current functional performance;provide treatment to optimize current functional ability,prevent deterioration,and/or modify maintenance program. Patient with c/o soreness but no reports of pain during therex. Verbal/visual/tactile cues for increased recall, problem solving, sequencing or overall technique. Utilized Patient completed x 15 minutes with PT facilitating interval training of varying resistance 1-2 minutes. Increased time needed to execute and allow for therapeutic rest. These examples will give you an idea of how you might perform a patients documentation. Under the maintenance coverage standard articulated in the Jimmo Settlement, the determining issue regarding Medicare coverage is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will "improve." of therapy can reasonably be expected to benefit the patient. How can a skilled maintenance program support this? I am a physical therapist working in Md. Patient with max cues for posture to reduce trunk sway with standing tasks. 1 0 obj Performing physical exercises during your maintenance therapy session can help with maintaining mobility and strength. A: Lisa Miliken: There is a great list of suggested skilled terminology to use for different clinical scenarios on the ASHA website:http://bit.ly/1Xc5BD1. Physical Therapy Coding Cheat Sheet Your Definitive Guide to Physical Therapy ICD-10 Coding, Physical Therapy CPT Codes Everything You Need to Know, What to Look for in Physical Therapy Software, Ten Ways to Speed Up Physical Therapy Documentation, How to FindMedical Billing Companies with the Right Vision for your Practice, Skilled Physical Therapy Documentation In Touch EMR Vs OptimisPT Physical Therapy Software, The Complete Guide to Medical Billing and Coding Software, How to Find and Screen Medical Billing Companies. endobj 1. endstream endobj 760 0 obj <. Group therapy documentation must demonstrate that group therapy is medically necessary and appropriate. Stabilized %%EOF Medicare, However, keep in mind that including one or two of these words/phrases does not in and of itself demonstrate skilled care, the therapist or assistant should use these key words/phrases in notes like the examples above. When considering how to approach setting goals for a patient receiving maintenance therapy delivered by a clinician, analyze the at-risk behavior or decline that would result from a lack of skilled intervention. Ea{:Aml,wjrtvk|,lVxSdt=/].I=hiciUyl=ixSNI6} VD.a>U;ai>>T>.]SNmRLjYSJ. i&mAGOg ($+Gdb:Er?Y$jO8"LWIMRMnv#Z;"wjX${C4qI3T\b)dE5ln!?[*l Review documentation for clinical observation and assessment, management of evaluation of care plan, teaching and training, skilled rehabilitation. The patient reports the surgery was performed with no issues. Patient is at risk for increased back pain without training to stabilize core muscles. This task is useful for meeting goals of independent dressing., The patient demonstrates poor scapular upward rotation with reaching. Patient now cleared to begin ROM exercises per MD documentation. No hard copies will be mailed. Physical Therapist: _______________________ Date:_________ Time: _________, Physician Signature: ______________________ Date: ________ Time: _________, Patient stated I am better able to sleep at night with less throbbing in my knee. Supervising They are entered in the patient's medical record by healthcare professionals to communicate information to other providers of care, to provide evidence . Skilled Maintenance Therapy Under Medicare, Several nonfederal payers also have clarified their policies, For Advertisers, Exhibitors, and Sponsors. Fax:1.800.839.0823 Recommend continue POC. Specific examples include hand assembly activities, transfers . Wed love to hear from you! 1. 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. Fear makes us focus on quantity as opposed to quality of documentation. All Rights Reserved. The patient lives with family who are able to assist driving him to appointments until cleared by a physician to drive. It is not necessary to establish rehabilitation or restorative therapy prior to the maintenance program, as long as the documentation justifies the need for skilled therapy to maintain function, or prevent or slow deterioration. O - Openly communicate earnest client responses. This is the foundation for the creation of the claim, and reimbursements. The conscious use of skill especially in the production of works. Improving serratus activation through protraction will aid in upward rotation of scapulae., Instructed the patient on performance of stairs x5 with multiple cues to lead with the appropriate leg on descent., Instructed the patient on performance of stairs x5 without upper extremity support for simulation of home environment., The patient demonstrated ability to properly perform front step up in order to navigate stairs at home., The patient demonstrates poor body mechanics in lifting a 5# object to a shelf overhead. T - Tactfully explain OT's unique plan for overcoming obstacles. Poor balance on an uneven surface noted during treatment. But there is a difference to covered and non-covered maint. Patient required mod vc with visual demo to execute properly to avoid injury. hbbd``b`$V w`" D 8AD,`T\Q@P#S(Fb 0 ( Documentation must support the need for Skilled Maintenance and clearly show a reviewer why the service could not be . Heres a thought why do we need to be defensive with our documentation? In closing, Harmony Healthcare International (HHI) encourages providers to educate themselves on Maintenance therapy and stay on the lookout for further educational outreach from CMS. Standing: mini squats x 10, hip abduction x 10 bilaterally, hamstring curls x 15 bilaterally, step up to 3 step x 10 alternating LE. Skilled therapy services are covered when an individualized assessment of the patient's clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist ("skilled care") are necessary for the performance of a safe and effective maintenance program. The patient will maintain ambulation to 250 feet without loss of balance or shortness of breath utilizing [devise or type of strategy i.e. The medical history form or the initial patient intake form establishes a foundation for identifying and treating the patients problems. 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 Patient was able to execute with no reported increase in pain in prep for gait training. To find out more visit our privacy policy. He was released home after a one-night stay at the hospital. When the treatment is designed to restore, improve, or compensate for lost or impaired functions, particularly those impacting activities of daily living, resulting from illness, injury, congenital defect, or surgery. endstream Today my pain level is 3/10.. Includes body functions: Examples of body functions include touch, pain, ROM, strength, tone, endurance, and breathing. Cold pack x 10 minutes in supine following ther ex. Without PT, patient is at risk for further decline as patient lives alone and was I with all tasks. Below is an example of documentation that is not best practice in support of a patient who is not clinically appropriate for group therapy, and an auditor's comment regarding the documentation. hbspt.cta._relativeUrls=true;hbspt.cta.load(56632, '6298b267-3733-4af6-937f-a9113a8083ee', {"useNewLoader":"true","region":"na1"}); Topics: Assistants are able to provide Skilled Maintenance Therapy to Medicare Part A residents in the SNF. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); This site uses Akismet to reduce spam. Ex. LEFS: 10% perceived impairment. Modified Patient is at risk for 10 minutes Neuromuscular Re-education (97112): Weight shifting on balance pad 320 seconds, Rhomberg stance on pad 320 seconds with one UE support, semi tandem stance with perturbations from therapist 21 min., rocker board for proprioceptive training x 3 min. Patient arrived at therapy with 3/10 L hip pain. Patient directed in NuStep training to increase biofeedback to BLE, mimic reciprocal pattern and increase overall BLE strength to decrease abnormal gait pattern. Of the 6 definitions of "art" listed in Merriam-Webster, 4 could be applied to the work that make up a part of every PT, OT and Speech therapy visit - documentation. 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. Patient will require further training to ensure I, recall, and overall competence with HEP prior to discharge. I like that we are able to talk to someone whenever we need to. Privacy Policy | Website Supported by Paradox Marketing, Harmony Healthcare International (HHI) Blog, Maintenance Therapy: Skilled Nursing Facility Goal Setting, 2023 Harmony Healthcare International, Inc. (HHI). Its a valid notion, but the reality of reimbursements leaves us no choice. Here are the top ten things you should know about providing Maintenance therapy. endobj Within 2 weeks, the patient will report a 20% reduction in knee pain at night in order to facilitate their ability to fall asleep. Not sure if this helps. The end point of therapy also needs to be clearly defined. The Jimmo agreement (Jimmo v. Sebelius) settles once and for all that Medicare coverage is available for skilled services to maintain an individuals condition. Patient reported it feels looser. Patient verbalized 3/10 pain post session indicating positive results from directed exercises. Graded 19. Examples of skilled maintenance services include: Establishment of a maintenance plan of care. This creates a vicious cycle where wedocument too much. Patient then instructed in 30 second planks x 3 with rest breaks in between planks to maximize tolerance. These dynamic activities must be part of an active written plan of care and be directed at a specific outcome. Advised patient on safe use of walker to encourage proximity to device. %PDF-1.5 % Max vc to execute properly. Rehab potential is excellent. See a certified medical, financial, or legal professional for advice. If and when you fall under the scrutiny of an auditor, the auditor will essentially ask: Why did the patient come and see you? PT facilitated patient in performing activity tolerance task incorporating UE and LE x 5 minutes x 2 trials with rest in between trials. Examples might include cognitive restructuring within CBT or relaxation techniques as part of a mindfulness training program. Patient instructed in single leg raise AROM with max vc and tactile cues to focus on quad contraction, quad sets (3 sec muscle contraction with max vc and tactile cues, heel slides with 3 sec hold in flexed position, hip abd with knee ext 2# with cues to maintain hip in neutral and overall correction of technique. 1. <> The most common causes of collisions in Jackson, MS include: Distractions from passengers. When considering a patient for a maintenance program, it is not essential that they have a chronic, progressive diagnosis. The patient will maintain _____ degrees AAROM UE to reduce risk of fixed bony contracture. 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 Steri strips are present along a 20 cm incision. What is the patients point of view? Click below to schedule a free demo with the experts at In Touch EMR, or call (800)-421-8442 to learn more. Verbal cues were provided to improve postural alignment and engage in pursed lipped breathing to maximize functional tolerance. All of this is possible thanks to clients across the country, who have embraced In Touch EMR. Patient required verbal cues for erect posture to maximize cardiopulmonary function. Therapist Signature: _________________ Date: _____________ Time: __________, Pain/Location: 2/10; Patient states, My knee pain has decreased significantly, allowing me to sleep through the night and to sit and stand from chairs much more easily. We are also a CMS recognized PQRS registry, we automate the reporting of PQRS and Functional Limitation G codes and provide automatic alerts for plan of care expirations, authorizations, progress note reminders and KX modifier alerts. Here are some additional guidelines for defensible documentation: In Touch EMR is a fully integrated scheduling, documentation and billing software for physical therapy practices. Although APTA documentation guidelines and most third-party payers require documentation for each physical therapy encounter, the format of treatment note documentation is at the discretion of each institution. Required max verbal cues, tactile cues and visual demo to reduce compensatory strategies. The patient will maintain tolerance for ___ splint as applied by occupational therapy and periodic skin assessment for s/s of redness. We know how it is to feel trapped by the never-ending paperwork. To help therapists and assistants improve their documentation, the following are examples of documentation that clearly demonstrates the skilled nature of therapeutic exercise. When treating patients, use shorthand to take quick personal notes about your interactions and observations. Pt instructed in posterior pelvic tilts 310 with 3 sec hold. 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. 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. Lower Extremity Functional Outcome Score: 55% disability score. Patient educated and instructed in R hip exercises to increase R hip ROM/strength for improved balance, pain reduction, as well as core strengthening to reduce compensatory strategies for improved posture. That doesnt tell us anything, and it neglects to mention any cueing you provided. 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. A skilled PT is required to address these key impairments and to provide and progress with an appropriate home exercise program. Patient was limited by pain and fatigue, but with encouragement and stabilization, improvement and tolerance noted. Maintenance therapy helps to maintain, prevent or slow unnecessary decline in a patient's . Send us a note. Treatment Provided: Total knee protocol to include instruction of HEP and performance of the following exercises: ankle pumps x 20, quad sets x 15, SLR x 10, sidelying SLR x 10, glute squeezes x 20, mini squats x 10, heel slides x 15. Hint 2: When you write the subjective section, you need to be as concise as possible. You know you are providing your patients skilled treatment. Patient denied SOB or pain, but reported that was a good workout. O2 monitored pre, during, and post exercise with readings > 94%. After intervention, was then able to carry out with intermittent cues for pacing and staying on task. We also provide you with an option to download done-for-you templates for documentation. Overall, patient completed x 15 minutes with PT directing patient with interval training of grading resistance 1-2 minutes. abMbout Maintenance Therapy Diana Kornetti, PT,MA Cindy Krafft, PT, MS . Establishment of treatment goals specific to dysfunction and designed to specifically address each problem identified in the initial assessment. Precautions: WBAT with FWW, progressing to cane as tolerated. Initial Patient/Client Management A. The 2013 Jimmo vs. Sebelius settlement sought to dispel this fallacy and provide clarifications to safeguard against unfair denials by Medicare contractors for skilled therapy services that aid in maintaining a patient's current condition or to prevent or slow decline. This disconnect between the want and the need creates afear. You worked hard to earn your degree. 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. Patient is L hand dominant. C9746 has been replaced with CPT code 0548T and 0549T effective July 1, 2019. Learn how your comment data is processed. Physical therapy documentation templates are simply a predetermined structure designed to reduce errors, increase efficiency, and improve job satisfaction. Reinforced proper posture and provided cues for safe lifting of items overhead throughout treatment., Provided verbal cues to correct for anterior translation of femur with squatting and to promote the appropriate body mechanics for sit- to- stand transfers and other functional activities., Instructed performance of squatting with a weighted object in order to improve sit-to-stand function. Patient instructed in RLE exercises to increase LE strength s/p R knee replacement. Documentation should include indication of no shows and cancellations. Maintenance Therapy, Are you a PT seeking one-on-one career coaching or help with documentation? 2 0 obj Author Beth Reigart. We want you to provide your patients with excellent care and be able to document well so you can treat them as long as medically necessary. Patient instructed in green TB exercises for chest fly, shoulder abd, shoulder flexion, elbow flex and extension 215. xn@-regm)Dii(zHMQ}g m(]9s|!|!PJIFx.{ l2;ga! If you ever get audited, the fact that you are using ONC-certified EHR technology (CEHRT) will work in your favor. My LE swells when I stand more than 3 hours at a time, but resting for 20 minutes allows me to stand throughout the day. Patient is active in his work as a floor manager at a local car manufacturer and could stand 8 to 10 hours a day, navigating stairs throughout the facility. It forces us to document. Observing Facilitated These sample phrases may be used in the objective (observational) or assessment (interpretation and judgment) sections of your therapy documentation. INSTRUCTED TO DO EXS 2X/DAILY; CRYOTHERAPY TO L HIP X 20 MINS WHILE SUPINE WITH L LE ELEVATED TO HELP WITH SWELLING. This blog about Physical Therapy Documentation Phrases has helped me a lot, is very well written. Long-term goals will be addressed with further treatment. A1: The Jimmo Settlement Agreement clarified that when a beneficiary needs skilled nursing or therapy services under Medicare's skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) benefits in order to maintain the patient's current condition or to prevent or slow decline or deterioration (provided all other . Thanks 10 minutes Cold Pack (97010): Left knee patient in supine with knee supported by bolster for comfort following exercises and treatment. 40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy, . 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. Documentation and reimbursement for physical therapy services when working with the pediatric population present some unique challenges. 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.
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