Daily, Progress, and Discharge Notes LAMP 1

Definitions Treatment/Daily Notes Progress/Reevluation Notes Documentation required for every encounter Support billing codes Forms, checklists, flow sheets Goals??????? Progress/Reevluation Notes Summarize patient’s response to Rx (progress) Measure Progress Toward Goals Change in POC?? Frequency dependent on facility, insurance, patient’s progress Discharge Notes Completion of episode of care or prior to transfer to another setting

Treatment/Daily Notes SOAP Subjective report from patient Interventions consistent with billing Equipment or written instructions provided Patient’s response to interventions O or A?? Factors leading to any modifications Communication/collaboration with other healthcare professionals

Progress Notes Info as in daily note Summary of patient response to PT interventions – patient progress toward goals Frequency dependent on facility, patient rate of progress (acute vs LTC), frequency of PT sessions, 3rd party requirements CMS requires progress note every 10 Rx or every 30 days (whichever is less) If time frames not set, progress notes should mirror goals time frames

Comparison of Info included in IE and progress note Initial Eval - S Interim Note - S Patient’s current and past medical Hx Symptoms or complaints Factors that cause symptoms Prior level of function Lifestyle/occupational roles Patient’s goals Current status Reaction to intervention New problems or new complaints Pertinent info not previously documented

Initial Evaluation - O Interim Note - O Information gathered through Tests Measures Observations Interventions provided Patient education Procedural interventions Patient’s response to interventions provided Patient status Data collected through tests and measures Patient’s functional status observations Interventions provided Patient related instruction Procedural interventions

Initial Evaluation - A Interim Note - A Summarization of S, O PT’s interpretation of the S and O data Identification of impairments and functional limitations Goals PT Dg Prognosis/rehab potential Justification for goals/Rx plan Suggestions for further testing, Rx, referrals Summarization of S, O Response to interventions Reference to patient progression toward goals established in POC Modifications to Goals New Goals Justification for continued or d/c PT

Initial Evaluation - P Interim Note - P Plan for intervention activities to occur Collaboration/communica tion Patient-related education Procedural interventions Frequency/duration of services Rx progression Plans for further assessment Equipment needs Referral to other services What actions needed to occur within areas of intervention Collaboration/communic ation Patient-related education Procedural interventions When the next Rx session scheduled Equipment or info that needs to be ordered or prepared before next session Interventions: what, amount (dosage, reps, distance), equipment used, setting on equipment, specific Rx area, patient positioning, duration, frequency, rest breaks Each document should be able to stand alone – don’t write rx plan as outlined before

Re-exam and Re-eval “process of performing selected test and measures after the initial exam to evaluate progress and to modify or redirect interventions” Guide to PT Practice, pg 47 Change in patient status warranting change in POC, dictated by state law, facility policy or 3rd party CMS requires significant change in patient status

Discharge Summary Completion of episode of care or transfer to another setting S: present status, improvement, pain, changes in functional or work status O: summary of services provided, patient’s status/data collected A: summary of goals (met, not met/rationale), rationale for DC P: DC plan activities (referral, HEP, future followup)

Consider the following: EXAMPLE: Consider the following: “Patient tolerated treatment well” Does this show Medical Necessity? Does this demonstrate skilled care? Does this show progression of the patient/client?

MEDICAL NECESSITY Therapy services are considered reasonable and necessary when the following conditions are met: The services provided are consistent with the nature and severity of the illness, injury, and medical needs. The services provided are specific, safe, and effective treatment for the condition according to accepted medical practice. There should be a reasonable expectation that observable improvement in functional ability will occur. The services do not just promote the general welfare of the beneficiary.

MEDICAL NECESSITY Fall risk Document complications and safety issues as a result of the patient/clients current status. Fall risk Reduced mobility – increase risk for further complications Inability to complete tasks (ie, activities of daily living)

SKILLED LEVEL OF CARE Services must be at such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified physical therapist or under his/her supervision/direction. The services must require the expertise, knowledge, clinical decision making or problem solving, and abilities of a therapist A therapist’s skill may also be required for safety reasons.

EXAMPLES OF SKILLED LEVEL OF CARE Patient educated in the use of progressive exercises to facilitate trunk stabilization for improved balance during gait. Training provided in donning/doffing lower extremity prosthesis with verbal and manual cues for technique and safety. Ambulation training with standard walker. Patient requires frequent monitoring of vital signs due to poor endurance and cardiac risk factors. Patient demonstrates consistently good balance on level surface, therefore progressed patient to performing standing balance activities on unstable surface to decrease fall risk and increase community ambulation safety.

Consider the following… EXAMPLE Consider the following… “Therapeutic exercise and right shoulder mobilization including AP glides of the glenohumeral joint resulted in increased flexion from 90° to 110° allowing the patient/client to reach overhead and independently complete ADLs.” Does this show Medical Necessity? Does this demonstrate skilled care? Does this show progression of the patient/client?