The two most important requirements for PT/OT documentation are to demonstrate that the care is (1) medically necessary and (2) competent.
Nursing is considered "trained" only when it has a level of sophistication and complexity that requires the services of a therapist or a therapist-supervised assistant. Services that do not require the performance or supervision of a therapist are not considered "appropriate" even if performed by a therapist. Researchers often rely on redundant or otherwise incomplete documentation to deny a claim, concluding that therapeutic practice does not require the skills of a therapist.
A therapist's skills can be documented through descriptions of specific treatment, changes in treatment based on an assessment of the patient's needs on a particular day of treatment, or changes due to progress that the therapist deemed sufficient to advance the treatment to the next more complex or difficult one. job change.
To help therapists and assistants improve their documentation, below are examples of documentation that demonstrates the professional nature of therapeutic practice. (Technical terminology is highlighted in red.)
1. Patient came to treatment with 3/10 L hip pain. Patient was instructed on L-hip exercises to increase L-hip range of motion/strength for improved balance and overall pain reduction. In the supine position, the patient was instructed in 3 × 10 L hip abduction and L hip extension with verbal cues to isolate targeted muscle groups and initiate appropriate exercises. Min A is provided due to weakness of LE and prevention of replacement moves. Exercise since the last reporting period resulted in a 5 degree increase in hip L abduction. The patient was able to walk in preparation for gait training without an increase in pain.
2. In a seated position, prior to the functional mobility task, the patient was instructed in LLE strengthening exercises to reduce left leg drop during walking. Patient required minimal verbal cues and a visual demonstration to initiate each exercise with 2# ankle weights for knee flexion/extension B. With tuberculosis erythematosus, pt. trained in ankle dorsiflexion, plantarflexion, inversion/inversion with 3 second hold. Maximal verbal cues, tactile cues, and visual displays are required to reduce compensatory strategies. PT assisted patient to full standing, including heel raises with BUE support, using a mirror for visual feedback to ensure proper form, 2×15. Increased time required to conduct and provide therapeutic rest. Patient reporting exercises help him "not stop me so much."
3. The patient is instructed in NuStep training to increase BLE biofeedback, mimic the reciprocal pattern, and increase total BLE force to reduce abnormal gait patterns. Patient completed x 15 minutes of PT, allowing 1-2 minutes of variable resistance interval training. The patient required verbal cues to maintain an upright position in order to maximize cardiopulmonary function. O2 is monitored before, during and after exercise with O2 >95% to ensure a positive response and reduce the risk of desaturation. The patient denied dyspnea and stated that it was just the right challenge.
4. The patient is instructed in supine BLE exercise to increase overall functional activity tolerance and LE strength to maximize balance and reduce falls during mobility. Patient managed by physical therapist x 18 minutes requiring two periods of therapeutic rest due to complaints of fatigue and increased breathing. The physiotherapist used the modified Borg scale and the patient gave a score of 2/10 during exercise. O2 >96% when monitored during rest periods, RR 22 postexercise, 18 at baseline. The patient was also instructed in lip breathing to relieve complaints of shortness of breath and to encourage the use of energy-saving techniques. A well-executed visual demonstration can be imitated.
5. Patient presented to an experienced OR complaining of 5/10 R shoulder pain limiting UE bandaging tasks. R-Shoulder ROM measurements were performed as follows: OT assessed and measured R-Shoulder Flexion: 60 degrees, ABD: 58 degrees, EXT: 20 degrees, IR: 20 degrees, ER: 25 degrees. The patient was instructed in the following exercises to increase RUE ROM, decrease stiffness, and decrease pain levels: Cable Pull 1-2 minutes x 3 attempts to increase shoulder flexion, with short rest periods between attempts . The patient reported no increase in pain. The OT individualized and instructed the patient on AROM exercises to maximize the patient's range in the pain-free zone as follows: IR/ER, abd/add 1×10, extension with 3 second hold. The patient reported, "Feels more relaxed." The patient reported 3/10 pain after the session, indicating positive results from the targeted exercises.
6. The physical therapist trained the patient in hand B strengthening exercises after the assessment to improve overall grip/grip. The patient trained the following moderate resistance putt exercises to improve gross grip and various twists: gross grip, resistance, ab/add, edge pinch. Patient required VC and visual demonstration for proper fit. After training, gross grip was assessed by OT and measured: 40# L, 42# R, 7# tip trap bilateral (2# improvement per hand for gross grip and 1# improvement bilateral for tip trap during last session). The patient denied pain and complained only of general "weakness." The patient reported functional benefits in opening jars in preparation for feeding and grooming tasks.
7. Patient is instructed in the following exercises to increase left wrist/hand range of motion, decrease stiffness, and relieve pain to use left hand in s/p wrist fx work. The patient is now allowed to begin ROM exercises as per MD documentation. The patient is left-handed dominant. Patient is positioned in L-wrist flexion/extremity, radial/ulnar deviation, contrast, finger extension/posterior flexion, MCP flexion/extremity, PIP flexion/extremity 2×10 with therapeutic rest as needed. Tactile, verbal and visual cues are required to isolate targeted muscle groups. A radial/ulnar deviation was noted in one patient with difficulty. Therefore, the OT stabilized the patient at the wrist to perform accurately and the patient was able to complete the task with less pain overall.
8. Patient is instructed on UE bike to maximize UE range of motion and strength to improve overall function in tasks. The OT graded the task based on the patient's response to the training. The patient was assigned level 1 resistance for 5 minutes, then level 2 resistance for 5 minutes, and finally level 3 resistance for the remainder of the task. The patient denied sobbing or pain, but reported, "It was a good workout." O2 was monitored before, during and after exercise with values >94%. Verbal cues were given to improve postural alignment and engage in lip breathing to maximize functional tolerance. Increased time required for proper positioning prior to training to ensure optimal work performance.
9. The patient presents to a specialist physical therapist after an exacerbation of CHF and reports shortness of breath while walking in the community. The patient is educated on the use of functional activity tolerance training techniques to improve overall lung function. O2 and RR levels were closely monitored throughout exercise with no abnormal response detected from baseline on patient assessment. The PT assisted the patient to complete an activity tolerance task consisting of UE and PE x 5 min x 2 trials with rest periods between trials. The patient said, "Wow, I'm really out of shape," but was able to complete the task with training in energy-saving techniques.
10. The patient comes to a specialist physical therapist and fell in the patient's bathroom, resulting in right-sided hip pain and general weakness. Without a PT, the patient is at risk of further deterioration as he lives alone and has to complete all tasks on his own. Due to pain in the right hip, the patient had difficulty standing. In the supine position, the patient was instructed to bridge the right hip down/back, flex/extend, and 3×10 with tactile guidance for weakness. Increased time required due to R hip pain as well as ensuring proper form to prevent injury. More specialist services will be required to augment the weakened RLE.
11. OT developed HEP and patient instructed in self-exercise/stretching exercises to increase I with HEP for BUE exercises. Individual HEP training, review and exercise facilitation with minimal VC to start. The OT facilitated the patient to fully raise/lower the skull and retract/extend the skull with 1×10 and 10 second holds. The patient was instructed in TB exercises for thoracic swing, shoulder-abdominal flexion, shoulder flexion, elbow flexion, and extension 2×15. The OT modified tasks as needed to allow therapeutic rest needed to maximize strength and functional tolerance. The patient needs further education before discharge to ensure familiarity and overall knowledge of the HEP.
12. Patient presented to PT with 4/10 R hip pain. Patient is trained and instructed in R-hip exercises to increase R-hip range of motion/strength to improve balance, decrease pain, and strengthen core muscles to reduce compensatory strategies for improved posture. In the supine position, the patient was instructed in 3×10 R hip abduction using 2.5# weights, L hip extension in the prone position, and supine single leg raise to the patient's maximum tolerance. Can complete 15 of each exercise before switching tasks due to fatigue. The patient is instructed to perform 3×10 pelvic tilts backward with 3-second holds. PT Score One Leg Standing Work for Hip Flexion and Abdominal Flexion on Conforming Surface 3×10. The patient completed the standing Achilles tendon 3x 30 seconds with modern verbal cues for pain-free technique and movement. Minimum A is provided due to inability to RE and prevent replacement moves. The physical therapist assessed the progress as follows: an increase in right hip flexion of 4 degrees, hip abduction of 3 degrees, and extension of 2 degrees after the Ex session compared to the previous session. The patient was able to perform the exercises in preparation for gait training without increasing pain.
13. The physical therapist developed a functional activity tolerance program and instructed the patient in NuStep training to increase biofeedback for BLE, mimic reciprocal patterns, and increase total LE force to reduce abnormal gait patterns. In total, the patient completed x 15 minutes of PT, which guided the patient through 1-2 minutes of graded interval resistance training. O2 monitoring before, during and after training with O2 values > 95%. The physical therapist provided cues to keep the hips in a neutral position during the task, cues to maintain SPM > 55, and cues to pursed-lip breathing. Post-task RR <20 and RPE 2. With PT direction, the patient completed the task with symmetrical motion 90% of the time.
14. The patient is instructed on RLE exercises to increase LE strength during knee arthroplasty. The PT instructed the patient in the following exercises to improve functional ROM to allow for an improved gait pattern and reduce the risk of falls during standing work. Patient is positioned in single leg AROM raises with max vc and tactile cues to focus on quadriceps contraction, quad sets (3 sec muscle contraction with max vc and tactile cues, heel slide with hold 3 sec in flexion, hip abd with straight knee 2 #) admitted. with hints for keeping the hips in a neutral position and general technique correction. The patient continued this session with standing wall squats with physioballs and Min A, heel raises with BUE, and postural cues. Patient with maximum postural signs to reduce trunk sway during standing tasks. Patient with c/o 'pain' but no reports of pain during treatment.
15. The patient came to the OT to address incontinence management, including PMEs to reduce urinary urgency. The patient reports 3 episodes of nocturia with an increased risk of falling. The OT developed a program and the patient was instructed in various exercises to strengthen the pelvic muscles, reduce urinary urgency, and control the bladder to reduce falls overall. The patient is instructed on glutes, Kegels, hip-abdominal exercises, and hip exercises, engaging the pelvic floor for 5 seconds each, 3×10. The patient required an initial visual demonstration to isolate the targeted muscles and increase transmission. After the procedure, he was able to work with intermittent cues on pacing and staying on task. At the end of the session, the patient said: "I noticed that I can take more."
16. Patient presented with RLE weakness and decreased heel strike on gait assessment. The PT helped the patient perform the standing Achilles stretch and the seated quadriceps and HS stretches, 3x 30 seconds each, with modified technique cues and execution in the pain-free zone to improve gait pattern and maximize range of motion.
17. Patient came for treatment 6 weeks after humerus fracture R. New instruction from MD to patient to initiate ROM per protocol. The patient was specifically informed and instructed to do the Codman x 1 minute x 5 RUE clockwise then counterclockwise. OT provided shoulder stabilization to ensure proper form and prevent injury. Max vc to run properly. Between each set, the patient required standing rest periods and a total of two sitting rest periods. The patient was limited by pain and fatigue, but encouragement and stabilization, improvement and tolerance could be noted.
18. The patient came to the OT with RUE failure s/p CVA. After assessing the ease of muscle contraction, the patient was instructed in the following exercises to allow improvement of voluntary muscle movement. Patient is instructed on GE towel slides of flexion/extension and horizontal adduction/abd on 3×10 table surface with LUE support as needed. However, OT allowed forced treatment to increase RUE movement. The patient was frustrated at times, but the OT worked hand-in-hand with the patient when needed, resulting in improved performance.
19. The patient comes to treatment with sciatica. The patient is instructed to spiral, thigh stretch x 5 BLE and hold for 30 seconds each. Patient needs VC mod with visual display to work properly to avoid injury. The task was adapted and modified in response to patient discomfort, however, the patient's pain increased to 8/10 during stretching. The physical therapist stopped the pain reduction project and focused the program on pain management.
20. Without core stabilization training, the patient is at risk for increased back pain. The physical therapist taught the patient various core strengthening exercises to relieve back pain complaints. The patient is supine and properly positioned to perform 2 x 15 posterior pelvic tilts and abdominal crunches. Verbal and tactile cues are provided to isolate targeted muscle groups and reduce substitution methods. PT-rated work to perform standing side crunches with 5# weight x 10 on each side, using CGA intervals for balance. The patient was then instructed to do 30 second x 3 planks with rest periods between planks to maximize tolerance. In the next session, switch to at least 40 seconds of planks, but encourage the patient to do the exercises to fatigue.
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Words/phrases useful for skilled nursing documentation are listed below. Note, however, that the inclusion of one or two of these words/phrases is not in itself evidence of due diligence. The therapist or helper should use these key words/phrases in notes like the examples above.
• Rated
• Relieved
• Unterwiesen
• Changed
• Customized
• Supervised
• Rated
• Busy
• Stabilized
• direction
• Reduced
• Was founded
• Personalized
• The compensation strategy
• Causes
• The patient is at risk of...
• At home
• Second hand
• Verbal/visual/tactile cues for better recall, problem solving, sequencing or general technique
Words and phrases that therapists and assistants should avoid, as they often indicate a lack of expert care, include:
• Well tolerated
• Repeat speech (no session personalization/copy function)
• Notice
• Surveillance
• Proceed to POC
