Documentation Tutorial Defending the Clinical Process 1cAdvanced Institute of Rehab Services

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1 Documentation Tutorial Defending the Clinical Process Advanced Institute of Rehab Services 1 The Challenge of Documentation Historically Documentation has been a struggle for therapists Therapists want to treat the patients and can document the progress made but have a hard time justifying their services. 1

2 The Ruler We are primarily judged (and denied) not based upon progress, but whether we are really a necessary part of the process! Because our services are quite expensive, reviewers have every right to ask why are you still involved with this pt.? every week we continue to see them. The Good News we get to design the ruler that is used to make this judgment. 3 How are we accountable? We need to demonstrate why we need to intervene? Demonstrate a PLOF vs. CLOF on eval Propose a cause of that change in function. Propose methods of Reintegration (R), Compensating (C) and/or Modification (M) for that change. Design a way to measure our progresstowards R/C/M of that lost function. 4 2

3 When identifying CLOF we do so by assessing.. Functional Deficits (FD) and their correlating Underlying Impairments (UI s) 5 Why you/ Why now? Just about anyone can identify functional deficits. (The pt. was probably referred d/t this reason.) Use your skill to ID why the FD exists. Use your skill to ID the pathway to R/C/M for those FD s. When designing the ruler we outline what we work on in Rx to diminish the FD s as well as incorporate the U.I. s for those F.D. s. 6 3

4 Designing the Ruler Picture STG s on the Ruler. The top side shows F.D. s has noted gaps for progress. The bottom has U.I. s which can be used for the measurable impacts to achieve the F.D s (ROM, balance score, or components of swallow. FD UI FD UI CG MIN MOD MAX TOTAL REG MECH SOFT PUREE THIN LIQ NPO AIRWAY AP BOLUS TIMELY ORAL ORAL ATTEND PROT PROP CONTR SWALL AWARE SENS 7 Bottom Line: We need to show impact by: Measuring U.I. s. Link them to F.D. s so relationship to FUNCTION is obvious. Set goals on both. Increase L/E strength from 4 to 4+ to improve ability to rise for transfer Improve transfer from mod to min assist Analyze both in progress updates. 8 4

5 OCCUPATIONAL THERAPY SCOPE OF PRACTICE GRID Place severity rating in box: 1. stand by 2. Mild 3. Mod 4. Severe 5. Profound U N D E R L Y I N G I M P A I R M E N T S 1. Sensory a. sensory awareness b. sensory processing (1) tactile (2) proprioceptive (3) vestibular (4) visual (5) auditory (6) gustatory (7) olfactory c. perceptual processing (1) stereognosis (2) kinesthesia (3) pain response (4) body scheme (5) right - left discrimination (6) form constancy (7) position in space (8) visual-closure (9) figure ground (10) depth perception (11) spatial relations (12) topographical orientation 2. Neuromusculoskeletal a. reflex b. range of motion c. muscle tone d. strength e. endurance f. postural control/balance g. postural alignment h. soft tissue integrity i. gross coordination j. crossing the midline k. laterality l. bilateral integration m. motor control n. praxis o. fine coordination / dexterity p. visual-motor integration q. oral-motor control r. edema 4. Cognitive Integration a. level of arousal b. orientation c. recognition d. attention span e. initiation of activity f. termination of activity g. memory h. sequencing i. categorization j. concept formation k. spatial operations l. problem solving m. learning n. generalization o. safety awareness 5. Psycho/Social/Self-Expression a. self-concept b. role performance c. social conduct d. interpersonal skills e. self-expression f. coping skills g. time management h. self-control 6. Cardiorespiratory a. breathing patterns (diaphr.) Impact Rating on Function Scope of Practice Grid Underlying Impairment Bathing/ Showering Bed Mobility Community Activities Dressing Emerg. Resp./ Safety Proc. Feeding Functional Commun. Grooming /Hygiene Functional Deficits Home Management Joint Mobility Leisure/ Productive Activ. Meal Prep/ Cleanup Medication Routine Positioning Toilet Hygiene 9 Scope of Practice (Use the tools you have) Scope of Practice Grids have underlying impairments for all disciplines. Draws the line to F.D s. Have tools for OT, PT, ST just need to apply to documentation. 10 5

6 Critical Elements of Documentation Medical Necessity Skilled Service Skilled Analysis Interfering factors/prognosis Measurable Improvement Patient Stimulability Frequency/Duration/Intensity Pertinent Medical History Medical Necessity What is it? Defines the need for skilled intervention A change function related to recent medical history. Describe it? Links medical condition change in functional ability Justifies need for skilled intervention Explains impact to the patient cadvanced Institute of Rehab Services 12 6

7 Skilled Services What is it? The service that we are qualified to provide because of our specialized training and license It is our analysis and adjustments Describe it The observation, analysis, assessment, that results in the necessary adjustment of treatment goals, approaches and cueing strategies. cadvanced Institute of Rehab Services 13 Measurable Improvement Deciding the criteria Assuring measurable gain 1. Patient potential 2. Intensity of treatment 3. Writing an objective that is attainable -do you need a bridging step? 4. What level is really needed for functional ability cadvanced Institute of Rehab Services 14 7

8 Measurable Progress Are you reporting gains week to week? If so, have you upgraded the program to the point that the patient has reached their best ability to function? If not, have you documented adjusted treatment techniques and approaches? Or have you attempted to address a different underlying impairment that may be interfering? SOAP Element Example To write a good soap note, you need to have a plan! A consistent format reduces time spent in writing and ensures the content is complete. Here is a step by step process to learn!!! S. Optional information stated by resident or therapist opinion on patient attending, cooperation, tolerance of treatment etc. O. Objective data: Initial content needs to be: # of treatment sessions/# sessions scheduled. Skilled intervention included:.. needs to be next where you document the skill you used such as: choice of tasks; verbal cues; phonemic prompts; modeling; analysis of strength, range, and coordination of exercises; + reinforcement etc. (Don t make your reviewer have to look for this!!!) Then give the complete objectives. These need to be written either in narrative or column style, which gives each objective s data compared to baseline or the previous weeks information. I believe the column style is easiest for reviewers and staff to read. Then be sure to address all the caregiver training you conducted during that week. A. Analysis and Assessment: 1. Deal with each functional outcome individually. For example: Bill has increased the safety of oral intake as evidenced by reduced coughing and throat clearing at meals. This is due to increased tongue strength and increased ability to form a cohesive bolus Or: Bill has increase the safety and independence of ambulation as evidenced by using his w walker as trained throughout the facility. Or: Bill has increased the independence of self dressing as evidenced by no longer requiring assistance to button his shirt. 2. Talk about the skilled interventions which had the greatest/least impact: Bill s use of double swallow and chin tuck was more consistent requiring less verbal cues to initiate. 3. Discuss complicating factors having a negative impact in treatment that week. (Anything from the flu to death in the family!) 8

9 SOAP Element Example(continued) P. Prognosis and Plan: 1. Provide a prognostic statement regarding the likelihood of therapy success. Use you functional outcomes here!!! Prognosis is good for increasing the safety of Bill s swallow due to recency of onset, patient cooperation, and progress to date. 2. Explain the changes you intend to make to the care plan- whether it is a change of stimuli, task, response mode or type. 3. Then explain why the skills of a therapist remain critical for this patient s care: The skills of a Speech/Language Pathologist remain necessary to analyze Bill s swallow, determine safe diet texture modifications, train nursing on feeding techniques as they change. In addition, SLP will determine best exercises to increase quality of bolus formation. 4. The P section should also be where you indicate potential discharge time frame. The above format maintains medical necessity by use of functional outcomes in the objectives as addressed on the evaluation. It also maintains it by use of functional outcomes within the analysis/assessment portion of the note. Prognostic statements further support this where these are addressed again. The above format addresses Skilled Intervention for each objective via use of different conditions, tasks, response requirements, and timelines. This is elaborated on in the A section and the P section with changes in the plan being documented. The frequency and duration are justified because the clinical reasoning within this type of note is obvious. The R/C/M Continuum For each U.I. we determine where they fit into the continuum. Prevention<>Reintegration<>Compensation<>Modificati on Example: Pain <> Balance/Proprioception <> Strength<> Memory Prevention<>Restoration<>Compensation<>Adaptation 18 9

10 R/C/M Clinical Judgments (Several variable to consider) Consider PMH Past intervention they may have had Consider any precautions Assess cognition Consider possible D/C environment Consider presence of caregivers to assist in followthrough. 19 Designing Goals Types of Goals Duration of Treatment -Goals focus on active pt. involvement --Longer durations of Tx -Goals focus on positive and/or on caregiver inv. -Shorter durations of Rx Prevention Restoration Compensation Adaptation 20 10

11 Model of Care Reintegrate (Aligning U.I s with sample goals) OT PT ST REINTEGRATE Emphasizes restoration of underlying components that impact function Sample Goal Falls/Balance Falls/Balance sensory env. Stimulation, COG-sitting, Ther ex., PREs, ROM, stretching Improve trunk flexion ROM for safety during LE dressing. Medically complex posture, strength, breathing patterns, activity tolerance and vitals for activities. Enhance integration of sensory input as evidenced by a score of sec. on the MSIT to allow for. Falls/Balance sensory env. Stimulation, closed chain exercises, gait training, COG control training, Ther Ex., PREs, ROM, stretching Restore dynamic weight shifting ability. Medically Complex posture, resp. pattern, breath sounds, activity tolerance, vitals for tasks (BP, O2 sats, heart rate) Enhance ability to improve COG within BOS as evidenced by an increased score of inches on the Functional Reach, so pt. can do w/o loss of balance. Falls/Balance Sensory environment stimulation Improve problem solving Medically Complex breathing pattern for speech/swallowing, lung volume for breath support, swallowing Language receptive/expressive Cognition attention, memory, problem solving, reasoning, judgment, executive functions. Pt. will be able to lock brakes before standing 5/5 times by using training technique to prevent falling within 3 weeks. Sample Goal Chronic Disease Pt will demonstrate increased activity tolerance as demonstrated by the ability to perform lower body dressing with min asst. and Borg PRE score of <6/10 Pt will demonstrate increased activity tolerance as demonstrated by the ability to perform a standing activity for 5 min. with a Borg PRE score of <5/10 To increase phonation, patient will exhibit improved breath control as evidenced by increased VRI score of 2/4. 21 Model of Care Compensate (Aligning U.I. s with sample goals) OT PT ST COMPENSATE Teaches the pt. to compensate for deficits. The treatment focus is on the functional task, not on the underlying component. Sample goal Falls/Balance Assistive devices for ADLs. Teach the pt visual scanning techniques to compensate for visual field cut. Pt will perform UB dressing, grooming, bathing at I level with compensatory techniques. Falls/Balance Assistive devices for ambulation. Teach the pt. to use a rolling walker Pt will ambulate 75 with FWW with min. A of 1 to get to and from the bathroom within 3 weeks. Assistive devices for improving cognition memory book, cue cards. Compensatory techniques for Dysphagia, swallowing strategies. Establish consistent routine appropriate for cognitive level to maximize safety. Pt will use compensatory strategy of effortful swallow to decrease swallow delay to 1.5 sec. and decrease risk of aspiration 90% of the time. Pt will use compensatory memory aide to recall hip precautions 90% of the time to avoid re-injury

12 Model of Care Modify (aligning U.I. s with sample goals) MODIFY The task and the environment are the sources of change, not the patient. OT PT ST Environmental modifications eliminating barriers bedside table when getting out of bed. Contrasting colors, lighting. Alter colors within bathroom for improved safety (change-white toilet on white floor with white walls) Train caregivers Environmental modifications striking colors on w/c brakes to locate, move bedside table to decrease risk of falling, height of bed for transfers, lighting. Ask family to purchase more supportive shoes. Train caregivers Modify diet Contrasting colors to find room or locate other objects in room. Train caregiver in how to cue pt. Train caregivers Sample Goal Caregiver will stack clothing in sequence of donning over 3 consecutive observations to allow pt. to dress self. Caregiver will use designated footwear when ambulating pt. for cares on 3 consecutive observations for decrease risk of falling. Caregiver will verbally cue pt. to tuck chin when swallowing on 3 consecutive observations for decreased risk of aspiration. 23 Case Study/ Return Demonstrations Assessment Review Case Study Write a sample assessment Write sample goals STG s and LTG s Continuation of Treatment Write a sample visit/encounter note cadvanced Institute of Rehab Services 24 12

13 Quality Review Form HH Eval HOME HEALTH EVAL DOC AUDIT TOOL Therapist: Page 1 Patient: Discipline: PT OT ST SOC: Evidence Y N N/A of: Comments Medical Hx/Dx present, supports Intervention Reason for referral evident/ supports Rx PLOF compared to CLOF and justifies Rx Precautions/Contraindications documented Vital Signs (circle) BP - HR - RR Cognition- evidence of fxl deficit (Orient; person, place time,circumstance, STM, LTM, PS, Reasoning, safety) Pain documented w impact on fx Homebound reason clearly documented Med Changes documented Safety docmented and impact on fx Underlying Impair: Strength, ROM impact on fx Functional Assessment Test documented Skilled Gait Training (Inc. deviations, cues) HEP; response and return demo documented Plan of Care: Freq/Dur. # visits perf. If re-assess; PLOF/CLOF is outlined and r/t fx If POC update has analysis, adjustments, chng If POC Update: indicates prognosis to cont If POC Update: indicates remaining deficits STG specific, measureable, time frame STG show UI's and Fxl Deficits from eval STG's are related to LTG's LTG indicate end of Rx outcome Visits match orders for compliance Caregiver ed. and train documented w return demo Missed Visits w/document. Extra Visits w/ MD Order(s) Case Conferencing evidence of: PT - PTA - ST - OT - OTA - RN - MSW MD SOC D/C # FAT Submitted Each Doc Signed & Title CPT # Agency Branch SV Doc. w/ Conference Revised DATE: Reviewer: 25 Quality Review Form HH Progress Note HOME HEALTH: VISIT DOC AUDIT TOOL Therapist: Patient: Discipline: PT OT ST SOC: DOS: Evidence of: Y N N/A Comments Homebound reason clearly documented Med Changes documented Pain documented w impact on fx Vital Signs (circle) BP - HR - RR Objective Reporting: Underlying Impair: Strength, ROM impact on fx Missed Visits w/document. Summary of CLOF/limitations justifies Rx Precautions/Contraindications documented Safety docmented and impact on fx Functional Assessment Test chng documented Skilled Intervention Underlying Impairments relate to fxl impact Pts. response to treatment noted Doc of skilled therapy; analsysis, adjustment Prognosis/further gains expected and doc HEP: response and return demo documeted Plan of Care: Freq/Dur. # visits perf. Plan changes, adaptations noted Plan justified reason to continue Caregiver ed. and train documented w return demo Extra Visits w/ MD Order(s) Communication documented: PT - PTA - ST - OT - OTA - RN - MSW Each Doc Signed & Title CPT # Agency Branch SV Doc. w/ Conference Revised DATE: Reviewer: 13

14 Quality Review Form SNF audit tool Quality Review Form SNF audit tool 14

15 Documentation Cue Cards (can help outline the clinical process) Cue cards for evaluation forms PLOF comparing CLOF Reason for referral Analysis and adjustment Prognosis to continue Cue cards for progress note PLOF comparing CLOF Reason for referral Analysis and adjustment Prognosis to continue Documentation Samples 29 Documentation Cue Cards--HC 30 15

16 Documentation Cue Card- HC cont 31 Documentation Cue Card SNF 16

17 Documentation Cue Card SNF-cont Peer Review Provides clinical reasoning from peer to peer Provided unbiased review Can meet regulatory standards Provides didactic exchange for learning and clinical decision making 34 17

18 Compliance Review (optional) 35 What is Probe Edit? And Why Are We On It? Probe Edits and Reviews are part of a larger process that CMS uses to oversee the Medicare Coverage Process. The larger process is called PCA (progressive corrective action). PCA is similar to our own clinical process

19 Clinical Process VS. PCA Clinical Purpose Process. Monitor ID triggers that may indicate a pt. who needs to be screened. Triggers: wt. loss, falls, poor grooming/ hygiene PCA Purpose Process Probe Edit ID triggers that may indicate a provider that needs to be screened. Possible Triggers: ICD codes, CPT codes, Case mix, changes in billing patterns. 37 Clinical Process VS. PCA cont. Clinical Purpose Process. Screen Determine if triggers are pointing to a legitimate issue that needs to be investigated further. i.e., Briefly assess the pt. to see if the wt. loss really indicates a swallowing problem that may justify Rx. PCA Purpose Process Probe Review Determine if triggers are pointing to a legitimate issue that needs to be investigated further. Possible Triggers: i.e. Briefly assess the medical records (via ADR process) to see if high usage of key indicators; Alzheimer s ICD code, case mix index., that can indicate over-utilization that may justify intervention

20 Clinical Process VS. PCA Clinical Purpose Process. Evaluation Intensively assess the pt. to determine what needs to be done in order to diminish the issue. PCA Purpose Process Targeted Medical Intensively assess. Review the medical records (via a focused review of certain types of documentation) to determine what exactly needs to be done in order to diminish the issue. 39 Clinical Process VS. PCA Clinical Purpose Process. Therapy ID deficits, impairments, and a plan of intervention. PCA Purpose Process Corrective ID the provider s Action deficits, Underlying Plan impairments and a plan of intervention. Retroactive Penalizing Refunds, persistent Stop offenders. Placements, etc

21 Summary Build the Fire Wall Putting out the inferno isn t fun! 41 21