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Eli's Rehab Report

Practice Pointers:

Take Your Documentation to the Next Level, Part 1: The Initial Evaluation

If you’re not meeting these key standards, your reimbursement could be on the chopping block.

Stellar documentation has always been important, but now, more than ever, it’s a good time to develop good habits with outcomes-based payment systems on the horizon. 

Everything starts with a good initial evaluation. It is your reference and the foundation from which all your other treatments are formed. 

“If you can nail the initial evaluation and show why the patient needs therapy, you’re off to a very good start,” says Rick Gawenda, PT, president and CEO of Gawenda Seminars & Consulting

Follow these key guideposts for better initial evals:

Set the Stage With Prior Function

Before you note anything else, you must describe how the patient was functioning prior to the illness/injury/surgery, etc. “A lot of people miss this,” Gawenda says. “If all you say is how the patient is doing now, the payer doesn’t know if the status is any different from before.” 

Other important questions to ask at the starting gate, according to Donna Thiel, JD, partner with King & Spaulding in Washington, D.C., include: What was the patient’s status at the time of the admission to a therapy? What caused the patient to come to need therapy? Had the patient failed to heal in a different setting? Was he using different equipment? 

Example: Mrs. Jones was walking to the community center every day until the long winter kept her housebound. Her strength, balance and stamina had decreased dramatically. Her son reported increased depression. Doctors noted weight gain but ruled out medical issues and cleared her for a course of therapy aimed at getting her ambulatory again… (provided by Thiel).

Write Top-Notch Goals

Now it’s time to write goals based on the patient’s prior vs. current function. Taking time to listen to the patient, caregiver, family, etc., is key to determining the gap between prior and current function, and, therefore, forming the appropriate goals, Gawenda points out.

A good rule of thumb for goal writing is the acronym, SMART: Specific, Measurable, Achievable, Realistic, and Time-bound, points out Nancy Swigert, MA, CCC/SLP, BRS-S, ASHA Fellow and director of respiratory care and speech-language pathology for Central Baptist Hospital in Lexington, KY.

Example: Suppose you write the following goal for a speech patient: “The patient will be able answer questions with one-word answers.”  Although specific and concrete, it still falls short of all the SMART goal requirements. A true SMART goal might read, “Within four weeks, the patient will be able to answer questions with one word with 90 percent accuracy when given some gestural cues,” Swigert says.

Besides SMART, another important emphasis in goal writing is patient-centered functional goals. In other words, what specific activities are meaningful to the patient that he or she is struggling with? 

Example: “We could change the SMART goal above, based on input from the patient indicating frustration at interactions with staff: ‘Within four weeks, the patient will be able to tell the staff what she wants to eat and drink, and what clothes she wants to wear,’” Swigert says. 

This goal, however, does not follow SMART criteria, Swigert points out: Since the focus is on being able to participate in activities, measuring performance may seem difficult. Being present at every meal and each morning to see if the patient can really participate at this level is not a reasonable thing for the clinician to do. However, you could modify the goal to, “Within four weeks, the patient will be able to name common foods and drinks and items of clothing when given minimal gestural cues with 95 percent accuracy so that she can tell the staff what she wants to eat and drink and what clothes she wants to wear.” 

“Now it can be measured within a therapy session, but it still focuses on function and participation in an activity important to the patient,” Swigert says.

Pack a Punch With Outcome Tools

In addition to regular tested measurements and objective assessments, therapists may benefit from using outcome tools based on what’s most appropriate for the patient, Gawenda says. “For example, if you’re treating an upper extremity injury and this person has self-care and ADL deficits, you might have the person complete the DASH (Disability of Arm Shoulder or Hand) or the Quick DASH.”

“If, on the other hand, you’re treating a patient just out of back surgery, you might have him complete the Oswestry Disability Index, the McGill Questionnaire, or the Digital Pain Questionnaire,” Gawenda says.

Be sure to use sound objective measures substantiated by research, says Pauline Franko, PT, CEEAA, president and owner of Encompass Consulting & Education in Tamarac, FL. “Personally, I like function-based tasks such as the two-minute step test, 30-second chair rise, dynamic gait index, four-square step test, and physical performance test, for a very small example.”

Saving grace: “Using those outcome tools at the initial eval and periodically during the episode of care can help demonstrate progress to an auditor, especially when that progress is only minimal or minute,” Gawenda says. “At the same time, the tools can help support why therapy is still necessary if the patient has not yet reached their final goal.”

Don’t Rely on Clinical Facts Alone

Your “why” is just as important as your “what.” Clinical facts don’t speak for themselves, especially to an auditor or medical reviewer. Your medical judgment needs to be in the mix, too.

“Medical review is not intended to be a clinical reevaluation or ‘second guessing’ of the treatment decisions made,” Thiel says. “Practically speaking, therapists sometimes document the clinical facts but do not document the medical judgment processes that lead them to select one course therapy instead of another. Claims may be denied if the rationale for rejecting a different (i.e., less intensive or less expensive) treatment is not spelled out in medical records or clinical notes,” she explains.

Try this: Thiel recommends thinking of it as a two-step documentation process: “I observed this___ and I recommended this_____.” 

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