Documentation-It's All About Proving the Skill

Once upon a time, demonstrating progress in therapy was the primary indicator as to whether or not outpatient rehab services would meet medical necessity criteria. Over time and, most recently with the clarification of coverage for Maintenance Therapy in which functional gains are no longer a goal (or even expected), this focus has shifted.  Understanding the value of documentation and its critical role for coverage (and to demonstrate your skill and value as a therapist) is essential.  So -  “How is therapy evaluated for medical necessity?”   (so happy you asked!) The answer…    

“It’s all about the skill”

Demonstrating skill in documentation is a technique that can be learned and can be used in any practice setting. While historically, we have been taught the “SOAP” note format (Subjective, Objective, Assessment & Plan), I have found therapists do better with the documentation when they think about the “what, why and how”.  "WHAT" you did (this is a regulatory requirement to justify billing)" WHY" you did it (have a functional endpoint)"HOW" you provided the intervention  (how come it had to be a therapist/you?)

The What

My experience has been that therapists are very good at documenting the "what".  Exercise flow charts with regular progression in distance, reps or weights are often the norm for documentation.  For example, let's say that you are working with a patient at risk for falls with muscle weakness, abnormal heel-toe sequence, and shuffling gait pattern. Treatment is started and documentation on Visit #1 states "gait training x  45 feet with min cues for proper heel-toe sequence".  Next visit 45 is increased to 50 feet...   then...  55...  75...  150 feet.  This shows progress, but progress and skill are not the same thing. Progress is expected from exercise and it could be argued that the patient would have achieved this independently if the patient just kept walking (with or without you).  Sadly chances are that this claim would be denied as what you are showing is "ambulation" and not "gait training".    

The Why

The why is seen less often than the "what" in notes,  but is critical to explain the value of your therapy.  Why increase muscle strength by from 3 to 4+/5?   So that the patient can independently transfer from their favorite chair in the living room.  Why increase ROM by 10 degrees?  So that the patient can reach into her kitchen cabinet to retrieve dinner plates.   Another good reason?  To reduce the burden of care on the spouse.   This end point makes sense of your therapy to a non-clinician reader.   

The How

This is the area that most encounter notes are weak.   My belief is that therapists often do not recognize how valuable their skill or knowledge are to the success of a treatment program and therefore, most therapists fail to document this critical area which truly provides evidence for the "skill" of the intervention.  Yet therapists use their skill every day in ways most don't even realize. Here are some examples of documentation that demonstrates skill.   

  • "Educated the patient and caregiver on fall prevention techniques and advised to remove throw rugs in bathroom to help prevent falls."

  • "Manually controlled  and guided for correct scapulo-humeral rhythm and corrected position in scapular plane."

  • "Determined that patient program could not be advanced today due to the combination of reported fatigue and pain and continued same regimen while reinforcing proper technique."

  • "Monitored patient vitals thorughout the treatment session with adjustments as necessary to promote safe cardiac response".

What trick did I just use?   The answer... "Action Verbs".  Action verbs are one of the easiest ways to improve documentation and demonstrate skill without significantly increasing your time or reducing your efficiency with documentation. Used effectively, they describe actions that only a therapist could provide since they require both knowledge and skilled judgement to respond to a patient's individual needs.  

And finally, don't forget the "who"....

One final note.  Patients are not a series of connected parts or just a diagnosis.  Patients and their family, friends and caregivers come to us with wishes, hopes, dreams and fears that are as important for us to consider as their functional recovery or response (and in fact directly impact that recovery or rehabilitation process).  Including the patient or family's goals and response to the treatment is extremely valuable in showing the person behind the disease.  For example, documenting "Pain level 3/10" is not as insightful as, "Patient met me with a smile today for the first time, stating that she was able to have her first full night's sleep since the injury due to her decrease in pain".