1. Daily, Progress, and Discharge Notes
LAMP 1

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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?

12. 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.

13. 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)

14. 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.

15. 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.

16. 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?