Home care clinicians all learn basic assessment skills during their formal education and clinical training that are pertinent to their profession. Nurses, therapists, and social workers each assess various areas of concern and document in a manner that identifies specific patient problems in their respective areas.
Therapy documentation is the most highly scrutinized by Medicare intermediaries due to the financial implications that therapy has on reimbursement. Inadequate or sub-standard documentation can lead to denial of payment for specific therapy visits or cause a full focused review of all therapy services. Initial therapeutic assessment followed by periodic measurements and assessing during the process of care should culminate in a final discharge assessment. This formula will ensure that your documentation not only withstands the scrutiny of review, but also demonstrates the skilled care in your therapy visits and reveals a favorable outcome.
It is vital that we therapy professionals assess and document like the well compensated, respected professionals we want to be viewed as by our peers. Therapy evaluations are a thorough compilation of measurements and analysis that provides a diagnostic study of a patient ‘s physical condition. Vital signs, pain, posture, edema, ROM, strength, balance, function, mentation, sensation, endurance, mobility, safety and gait should all be measured and analyzed in an objective manner. This will provide a therapeutic appraisal (assessment) of a patients rehab needs and potential. From this process a problem list is formulated which then leads to a treatment approach to address each identified problem. To only document the treatment interventions performed each visit without periodically re-measuring and assessing the problem makes us appear less professional. But beyond that, it begs the question, œHow do we show progress? . To simply show a patient walking further or doing more reps or higher resistance with exercise is not enough. We should strive to frequently demonstrate our assessment capabilities, not just because of reimbursement issues, but also to separate ourselves as rehab professionals from personal trainers, fitness instructors and other exercise specialists.
This introductory article is a prelude to a four part series that will address many of the above mentioned areas of therapy measure and assessment. Hopefully it provides a review that will have you scrutinize your own assessment and documentation performance and challenge you to ask the question, Is there room for improvement? .