1. Documentation in Medical Settings
Jennifer Meyer

2. Purpose of Documentation
Communication tool
Document Progress
Legal Record of Services Rendered
Other professionals
Physicians
Families
Reimbursement Agencies
Legal Purposes

3. Evaluation Report
The evaluation report typically is a summary of the evaluation process, any resulting diagnosis, and a plan for service and may include the following elements
reasons for referral
case history including prior level of function, medical complexities, and comorbidities
review of auditory, visual, motor, and cognitive statu;
standardized and/or nonstandardized methods of evaluation
diagnosis
analysis and integration of information to develop prognosis, including outcomes measures and projected outcomes
recommendations, including
referrals to other professionals as needed,
plan of care—
treatment amount, frequency, and duration;
long- and short-term functional goals
Prior Level of Function – define – how would that look with no prior neuro history, how would it look with neuro history.

4. Treatment Note
A treatment note is a record of a treatment session and typically includes the following information regarding the treatment session:
date
location
patient response
objective data on progress toward functional goals with comparison to prior sessions
skilled services provided (e.g., materials and strategies, patient/family education, analysis and assessment of patient performance, modification for progression of treatment);
session length and/or start and stop time, as required.

5. Reimbursement Sources Need to Know
Is your intervention
SKILLED
Why can’t a nurse/CNA/family member/activities coordinator do what you are doing?
REASONABLE
Frequency, Duration, Site,
Individualized based on impairments and function objectively measured in evaluation
NECESSARY
To be necessary, little likelihood the patient will recover without the intervention

6. Skilled or Unskilled?
YGoal: Improve speech intelligibility of functional phrases to 50% with minimal verbal cues from listener.
“Pt continues to present with unintelligible speech. Treatment included conversational practice. Recommend continue POC.”
ntats THE

7. Skilled or Unskilled?
“Pt continues to have unintelligible speech production; unable to consistently make needs known. Intelligibility at single-word level: 60%; phrase level: 30%. Pt benefits from SLP's verbal cues to reduce rate of speech and limit MLU to 1-2 words. Listener has better understanding if pt points to 1st letter of word first. Pt demonstrated improved self-awareness of intelligibility relative to last week's session.”

8. A Word About Coding
October 1, 2015, new coding system went into effect
ICD-10 - International Classification of Diseases, 10th Revision, Clinical Modification
Used for:
Tracking public health conditions (complications, anatomical location)
Improved data for epidemiological research (severity of illness, co-morbidities)
Measuring outcomes and care provided to patients
Making clinical decisions
Identifying fraud and abuse
Designing payment systems/processing claims

9. Resources for IC9-10 List of Codes
Coding Principles

10. Ethical Responsibility
ASHA's Code of Ethics Principle 1, Rule M states: "Individuals shall adequately maintain and appropriately secure records of professional services rendered, research and scholarly activities conducted, and products dispensed, and they shall allow access to these records only when authorized or when required by law" (ASHA, 2010r). Further, the Issues in Ethics: Representation of Services for Insurance Reimbursement, Funding, or Private Payment prohibits misrepresenting coding or clinical information for the purposes of obtaining reimbursement (ASHA, 2010)

11. Final Thoughts Your documentation is THE legal record of treatment
If you provided an intervention and do not document it, it “didn’t occur”
Reimbursement specialists, physicians, regulatory agencies and attorneys will review your documentation as the only record of what occurred during your intervention
You are your Documentation

12. Nationally, more resources (financial, personnel and time) are put into training rehab employees on documentation than on any other single area of training