maintenance physical therapy documentation examples

Patient presents to skilled PT following CHF exacerbation with reports of feeling breathlessness with community ambulation. <> Use Shortcuts to Save Time. With an identified deficit or quality of performance, Reason for Therapy to continue. or Key impairments to be addressed with further therapy in order to , Its not enough to simply say, The patient performed the exercises with good form.. 17. Patient trained in the following exercises using moderately resistive putty in order to increase gross grasp and various pinches: gross grasp, opposition, abd/add, tip pinch. xn@-regm)Dii(zHMQ}g m(]9s|!|!PJIFx.{ l2;ga! Patient progressed this session to standing wall squats with physio ball and min A, heel raises with BUE support and cues for posture. Recommend continue POC. 40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy, . Students and therapists alike have experienced difficulty locating helpful physical therapy documentation examples. T - Tactfully explain OT's unique plan for overcoming obstacles. Since In Touch EMR has been very proactive at staying at the forefront of emerging guidelines for EMR vendors, you are assured higher quality, higher security and more compliance with CMS and other payer regulations. What are the skilled areas that require maintenance therapy? During Harmony Healthcare Internationals (HHI) LTPAC Interdisciplinary Symposium, harmony16, guest speaker, Ali Bers, Attorney with Center for Medicare Advocacy shared her knowledge and passion for supporting ongoing skilled services to our elder population. Patient then instructed in 30 second planks x 3 with rest breaks in between planks to maximize tolerance. No assistive device used. , Educated the patient on proper performance of sit-to-stand, emphasizing body mechanics and proper alignment of knees.. So wewantto treat patients butneedto document. Skin appears dark pink, dry and well healing. In supine, patient instructed in R hip abd/add, flex/ext, bridging 310 with tactile guiding due to weakness. The patient has achieved 100% of short-term and long-term goals. Patient rates pain at 4/10 at present, 3/10 at best and 6/10 at worst. See privacy policy and disclosure page for details. C9746 has been replaced with CPT code 0548T and 0549T effective July 1, 2019. OCCUPATIONAL THERAPY DOMAINS Performance skills refer to "goal-directed actionsthat are to develop a key of frequently used abbreviations on most documentation forms or request therapists to completely spell any word the first time it is written with the shortened form in parentheses (e.g. Skilled Maintenance Therapy Under Medicare, Several nonfederal payers also have clarified their policies, For Advertisers, Exhibitors, and Sponsors. Within 2 weeks, the patient will achieve 90 knee flexion consistently in order to progress with functional activities such as rising from a chair with equal weight bearing. 2021 PTProgress - Our content does not constitute medical, financial, or legal consultation. CPT 97112 means "neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.". Most of the difficulty in writing defensible documentation lies in the assessment section. 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. Not sure if this helps. 2023 PT Management. Skilled Maintenance Therapy Under Medicare | APTA Physical Therapy Documentation: 3 Examples. endstream endobj 760 0 obj <. The change to allow PTAs to treat came with the 2021 Physician Fee Schedule Final Rule, in which CMS permanently permitted physical therapists to delegate maintenance therapy services to a PTA for outpatient services under Medicare Part B. SUPINE EXS QUAD AND GLUT SETS X 10; HEEL SLIDES, SAQ, IR/ER, PASSIVE HIP ABD AND ACTIVE HIP ADD, LAQ X 10 WITH L LE; STANDING TOE RISES, MARCHING IN PLACE, HIP EXT AND HAMSTRING CURLS X 10 WHILE HOLDING ONTO WALKER FOR SUPPORT. poor foot clearance, improper hip alignment, impaired posture, increased stress, further irritation. 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. All In Touch EMR customers get unlimited support via phone, email and live chat. Jimmo, Data collection is the foundation for monitoring progress, but, in itself is a daunting task. Patient denies tenderness behind the knee and along the incision. Facilitated We support this therapist owned EMR company wholeheartedly., Matthew S. Fischer, MSPT Fischer Physical Therapy, In my 30+ years as a compliance auditor, author and instructor, I have yet to see an EMR and billing software as comprehensive as In Touch EMR. OT provided stabilization at the shoulder to ensure proper form and to prevent injury. Prior Functional Level: Patient was independent in all areas. If and when you fall under the scrutiny of an auditor, the auditor will essentially ask: Why did the patient come and see you? Our biller is able to pull up detailed reports, exactly the way we want. PDF GUIDELINES FOR PHYSICAL THERAPY DOCUMENTATION BOD 02-02-16-20 (Program If they are, are the skills of a licensed therapist needed? Patient instructed in 5 minutes of level 1 resistance then graded to level 2 resistance for 5 minutes and finally level 3 resistance for the remainder of task. It is considered skilled to instruct caregivers and to periodically determine if they are carrying out an unskilled service. abMbout Maintenance Therapy Diana Kornetti, PT,MA Cindy Krafft, PT, MS . PDF Documentation Requirements for Procedure 20 minutes Therapeutic Exercise (97110): Supine exercises included: active quad sets x 15, SLR x 15, Hamstring curl x 10 with ankle dorsiflexion x 3 each rep, SAQ with bolster x 15. Posture: Patient stands with forward flexed trunk position using walker and demonstrates a favoring of the left knee in keeping it flexed. 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. The two most important PT/OT documentation requirements are demonstrating that care is (1) medically necessary and (2) skilled. All of this is possible thanks to clients across the country, who have embraced In Touch EMR. Why cant we just focus on patient treatment, and not be burdened by endless documentation? The patient will perform oral motor exercises to maintain functional oral motor strength for speech and swallowing capabilities daily with speech therapy cuing and supervision. How Should I Handle Back Pain After a Car Accident in Jackson, MS? Each requires evaluations, goals, plans of care, billing supported by skilled documentation, and . Treatment included conversational practice. 16. 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. WEBINAR `T81:^acePnaTcskG?IF\@\R XAaH200 ~# endstream endobj 200 0 obj <>/Metadata 10 0 R/Pages 197 0 R/StructTreeRoot 28 0 R/Type/Catalog>> endobj 201 0 obj <>/MediaBox[0 0 612 792]/Parent 197 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 202 0 obj <>stream PT educated patient in B hand strengthening exercises post estim to improve overall grip/pincer grasps. Maintenance Physical Therapy - In Motion O.C. Very few vendors can make this claim, and they generally wont bring this up (in some cases, out of ignorance) mostly because this is not a mandatory certification, it is optional and requires a significant investment of time and effort. Therapy, Patient used FWW to ambulate into clinic with equal step length noted. o Degree of goals achieved and reasons for goals not being achieved. No open areas noted. 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. All products are digital and delivered immediately. Documentation should include the referral mechanism by which physical therapy services are initiated. Patient required verbal cues for erect posture to maximize cardiopulmonary function. Patient instructed in green TB exercises for chest fly, shoulder abd, shoulder flexion, elbow flex and extension 215. Send us a note. Care is regarded as skilled only if it is at a level of complexity and sophistication that requires the services of a therapist or an assistant supervised by a therapist. Physical Therapy Documentation Best Practices & Tips But whether you practice pediatrics, orthopedics, or neurological therapy, best-practice guidelines and examples are an effective way to ensure your notes are useful and complete. Its a valid notion, but the reality of reimbursements leaves us no choice. PT instructed patient in the following exercises to improve functional ROM to facilitate improved gait pattern and reduce falls risk with standing tasks. I can walk for about 20 minutes with the cane before I need to sit to rest., Attendance: Number of Treatments: 7; Cancellations: 0; No Shows: 0, Treatment Included: Ther ex, neuromuscular re-ed, manual therapy, cold pack, HEP. PT graded task to perform in standing side crunches with 5# weight x 10 each side with CGA at times for balance. The 3 Most Common CPTs in Rehab (and How to Document Them for - BTE 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. of therapy can reasonably be expected to benefit the patient. Although they are written for a sample patient in an outpatient setting, you can use similar wording for the subjective, objective, and assessment goals in other settings (such as neuro, home health, skilled nursing, or acute rehab). 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. SOAP notes [1] are a highly structured format for documenting the progress of a patient during treatment and is only one of many possible formats that could be used by a health professional [2]. To help therapists and assistants improve their documentation, the following are examples of documentation that clearly demonstrates the skilled nature of therapeutic exercise. : educated pt for at home safety w/ emphasis on _________to improve (I) and return to PLOF. Medicare, . 3 Things I Wish I Knew Before Starting PT School, performs, demonstrates, reaches, achieves/does not achieve, lacks, displays, overhead lifting, reaching, pulling, gripping, squatting, lateral shifting, single-leg stance. to progress with stability training, to decrease the risk of falling, to safely manage lifting # items at home, to independently don/doff clothing, to perform head checks in vehicle safely, etc.. Graded Treatment notes are written for each encounter a PT or PTA has with a patient (Case Examples 12-1, 12-2, and 12-3). O2 and RR levels were closely monitored throughout exercise with no abnormal response from baseline when patient was assessed. Phone:1800.55.4CEUS (2387)Privacy Policy. Within 4 weeks, the patient will demonstrate independent ambulation on level surfaces without a straight cane in order to safely navigate the community without gait compensation. 11. O2 > 96% when monitored during rest breaks, RR 22 post exercise, 18 at baseline. PT developed functional activity tolerance program and instructed patient in NuStep training to increase biofeedback to BLE, mimic reciprocal pattern and increase overall LE strength to decrease abnormal gait pattern. Inhibit I had previously tried more complicated systems that made me exhausted at the end of the day. Its easy to use, it is concise, and it has a plenty of analysis variables to study., Sammy K. Bonfim PT Rehabilitation & Performance Center. Patient denied SOB or pain, but reported that was a good workout. O2 monitored pre, during, and post exercise with readings > 94%. The Physical Therapy (PT) daily note read: "AAROMEs of B LE x 20reps x 3 sets to improve strength and mobility of B LE. Patient is at risk for Patient was able to execute with no reported increase in pain in prep for gait training. 1. 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). In March of 2016 the Center for Medicare Advocacy went to court to enforce the ruling of the Jimmo settlement and they reiterated the inadequacy of the Educational Campaign that the Center for Medicare and Medicaid services were mandated to provide. Regardless of whether the skills services rendered are to improve, maintain, or slow deterioration, is Maintenance care required? 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. 2021 PTProgress - Our content does not constitute medical, financial, or legal consultation. Therapist Signature: _____________ Date: ____________ Time: _________. 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. Hint 1: It is a good idea to include direct quotes from the patient in this section. My management is now exploring analytics to identify areas of growth and efficiency and expect to drive our practice further with analytic insights. Fast forward 6 years, and Ive written thousands of physical therapy soap notes and helped hundreds of therapists with documentation examples and strategies on this blog. Within 6 weeks, the patient will demonstrate increased knee flexion AROM to 120 in order to improve the patients ability to descend 2 flights of stairs at work. Patient required standing rest breaks in between each set and 2 seated rest breaks overall. That doesnt tell us anything, and it neglects to mention any cueing you provided. O2 monitored pre, during and post exercise with O2 levels > 95% to ensure positive response and reduce risk of desaturation. Instructed The patient will maintain tolerance for ___ splint as applied by occupational therapy and periodic skin assessment for s/s of redness. Continued use of FWW recommended. Lower Extremity Functional Outcome Score: 55% disability score. Examples of skilled maintenance services include: Establishment of a maintenance plan of care. Please read my disclosure for more info. These sample phrases may be used in the objective (observational) or assessment (interpretation and judgment) sections of your therapy documentation. Assistants are able to provide Skilled Maintenance Therapy to Medicare Part A residents in the SNF. The patient reports the surgery was performed with no issues. Per usual, the Medicare law provides for up to 100 days of coverage per benefit period. 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. Are you a PT seeking one-on-one career coaching or help with documentation? Documentation Intake Paperwork Before the Visit, Download the In Touch EMR Intake Paperwork Templates Set, Defensible Documentation Proving Medical Necessity for Skilled Services During the Visit, Download the In Touch EMR Physical Therapy Documentation Examples Set, Need More Information about In Touch EMR? As clinicians, wewantto focus 100% of our energy on the patient, but instead we find ourselves transformed into data entry machines and glorified typists, of theneedtodocument too muchwhich creates an irrationalfearor denials. 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 . 759 0 obj <> endobj endstream Thanks (Skilled terminology is highlighted in red.). Then put whatever you mentioned for education. PT utilized Modified Borg Scale and patient reported 2/10 during exercise. Group Therapy in SNFs: What's Changed Under PDPM? JFIF ` ` vExif MM * > F( i N ` ` ICC_PROFILE appl mntrRGB XYZ acspAPPL appl -appl desc odscm x lcprt 8wtpt rXYZ 0 gXYZ D bXYZ X rTRC l chad | ,bTRC l gTRC l desc Generic RGB Profile Generic RGB Profile mluc skSK ( xhrHR ( caES $ ptBR &. CMS Initiatives/ Reforms: IMPACT Act of 2014, new factors in Five-Star quality rating, initiatives that prioritize improvement outcomes in function structural improvement, Inadequate research data on benefits of Maintenance therapy, Audit concerns about acquisition of fraud, preventing people from receiving medical care, Annual Medicare cap on certain therapies; reluctance to pursue exceptions, Manual mandatory medical review for claims exceeding certain thresholds. 4 0 obj 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. Patient completed x 15 minutes with PT facilitating interval training of varying resistance 1-2 minutes. Outlining patient progression through a series of goals that are achieved and modified is an excellent way to convey progress and justify treatment. Will require further skilled services to increase weakened RLE. Elicited The purpose of documentation is to demonstrate intent, the intent to bill certain codes and get paid by an insurance company. %PDF-1.5 % Here are the top ten things you should know about providing Maintenance therapy. PTs and PTAs are permitted to provide maintenance therapy services under Medicare Part A in home health and skilled nursing facility settings and across Part B settings. Progress to minimal 40 second planks next session but encourage patient to complete to point of fatigue. Patient is at risk for increased back pain without training to stabilize core muscles. Medically necessary services can be rehabilitative, maintenance, or slowing of decline, based on the physical therapist's ability to justify that they are reasonable and necessary and require the skills of the physical therapist. A well defined workflow for the front desk, clinicians, billers and coders makes this a one-stop shop for quick, compliant documentation and flawless billing. Therapist Signature: ______________ Date: ____________ Time: _________, Physician Signature: ______________ Date: ____________ Time: _________, Pain/Location: 0/10; Patient states, I no longer need to use the cane and have been able to navigate up and down my steps 8 times a day. For Advertisers, Exhibitors, and Sponsors | For Media. Wed love to hear from you! 2. Verbal cues were provided to improve postural alignment and engage in pursed lipped breathing to maximize functional tolerance. 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. Clients also get a self-paced video training program on how to get up and running, custom documentation template builder, iPad app one touch document import, Instant Intake iPad app, unlimited patient manager and patient portal. Social History: Patient is married and lives in a 2-story home with 4 steps to enter and 13 stairs to the basement and upstairs. Examples include: Home program. Objective Your practice can state that it carefully vetted and selected a rehabilitation-specific vendor that passed all of the ONC HIT 2014 Edition EHR Certification criteria required to satisfy the Base EHR definition. endobj Take personal notes. 2. OT developed HEP and patient instructed in self ROM/stretches to increase I with HEP for BUE exercises. Ins and Outs of Skilled Maintenance Therapy PT ceased task to reduce and direct program toward pain management. Best of all, the transition for our entire staff was streamlined and consistent and help was readily available. But there is a difference to covered and non-covered maint. 2023 Harmony Healthcare International, Inc.. All Rights Reserved. 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. Some examples listed on this site are: Instruct patient and caregiver in use and care of communication system. Chapter 10. Pediatric Documentation | Effective Documentation for These dynamic activities must be part of an active written plan of care and be directed at a specific outcome. The digital format allows for instant delivery and for greater customization on your end since you can copy/paste and save onto your own computer and tablet - or print pages as you need to. 1. Services that do not require the performance or supervision of a therapist are not considered skilled even if they are performed by a therapist. LEFS: 10% perceived impairment. 12. Tim Fraticelli is a Physical Therapist, Certified Financial Planner and founder of PTProgress.com. Patient with c/o soreness but no reports of pain during therex. lets get skilled. Its a no brainer forget the hype from other products and get In Touch EMR, Cheryl House RMC, CHI Compliance Auditor, Author, Coder and Instructor at Illinois Valley Community College, I was looking for a Practice Management Software that combined both documentation and billing platform systems that work in unison. Patient lacks full strength to ascend full flight of stairs reciprocally and demonstrates impaired balance on dynamic surfaces. PDF Documenting Skilled Need in Therapy Notes Patient arrived at therapy 6 weeks post R humeral fracture. 1. Review documentation for clinical observation and assessment, management of evaluation of care plan, teaching and training, skilled rehabilitation. Not only has the staff at In Touch EMR been proactive in adding new features and responding to support calls and streamlining our billing processes, they have been understanding, professional, polite and patient. In addition to supervising the services provided by the PTA, the qualified therapist is still responsible for the initial assessment, plan of care, maintenance program development and modifications, and reassessment every 30 days. A lot of therapists think that they can just cramp in a few notes after the sessions or write down what they remember within the week, but notes-taking, especially for therapy, doesn't work that way. Patient was able to execute with no increase in pain in prep for gait training. 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. Therapy services include occupational therapy (OT), physical therapy (PT), and speech therapy (ST). o Discharge/discontinuation plan related to the patient/client's continuing care. A therapists skills may be documented by descriptions of skilled treatment, changes made to treatment due to an assessment of the patients needs on a particular treatment day or changes due to progress the therapist judged sufficient to modify treatment toward the next more complex or difficult task. Thats why this article on10 ways to speed up physical therapy documentationshould help. Fear makes us focus on quantity as opposed to quality of documentation. This disconnect between the want and the need creates afear. This creates a vicious cycle where wedocument too much. The rationale for clinical decisions must be documented at regular intervals. Increased time needed due to R hip pain as well as to ensure proper form to prevent injury. Learn how your comment data is processed. It can also be the cause of major headaches, rushed lunch hours, and excessive typing throughout the day. Documentation should include indication of no shows and cancellations. 443-850- 0421, Pt continues to disregard side rails (whatever theyre being non compliant with, cane, crutches etc. [Blog Series] Group vs. Concurrent Therapy Part 1: Are You Documenting 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. Inexperienced drivers. The emphasis is placed on prior level of function and typically has a higher intensity and shorter duration. Within 6 weeks, the patient will report the ability to walk for 45 minutes without knee pain in order to perform work tasks such as navigating the plant facility. Medicare coverage for ongoing maintenance physical therapy 784 0 obj <>stream To find out more visit our privacy policy. Patient instructed in UE bike to maximize UE ROM and strength for improved overall function in tasks. The Note Ninjas - Physical Therapy, Occupational Therapy Patient reporting 3 episodes of nocturia increasing risks of falls. Patient reports decreased sensation along the incision line; sensation is intact otherwise. PROM flexion to 95 degrees. 7. No signs of infection noted. The Jimmo Settlement confirms that Medicare coverage is available for skilled nursing and therapy that is needed to maintain a persons condition or slow deterioration, for nursing home, home health, and outpatient therapy. SOAP Notes - Physiopedia 26 N. Beach St., Suite A 6 0 obj No hard copies will be mailed. _[a@>Ak*-'*571?SpnpfC6B@"FVYx7Bl)$[E_}md_`x2Xs8Yy Assessment Statement: Patient presents with signs and symptoms consistent with diagnosis of L knee OA, s/p 1 week post operative L TKA.