maintenance physical therapy documentation examples
17. Increased time needed to execute and allow for therapeutic rest. The treatments that are provided are they absolutely necessary? Patient needed stimulation . Patient rates pain at 4/10 at present, 3/10 at best and 6/10 at worst. Disclosure: This post may contain affiliate links, meaning I may get a commission if you decide to make a purchase through my links, at no cost to you. 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. Send us a note. PT facilitated patient to complete standing Achilles stretch and seated quad and HS stretch, 3x 30sec each with mod cues for technique and to complete in pain free range for improved gait pattern and maximize ROM. If and when you fall under the scrutiny of an auditor, the auditor will essentially ask: Why did the patient come and see you? Some examples listed on this site are: Instruct patient and caregiver in use and care of communication system. DO NOT assume Medicare is unavailable based on: Rules of Thumb, Diagnosis, Wants or Needs. endstream Rather than singular phrases, document the billing code, the body part (s) treated, the muscles and joints targeted, and the specific activities performed, such as isometric or isokinetic exercises. The patients goals are to return to work as a supervisor at the local car manufacturer, and to walk without a walker or cane as soon as possible., Past Medical History: High blood pressure, Previous PT: Yes, home health 4 days after surgery, Meds: Norco, tramadol, aspirin, lisinopril. Patient is at risk for increased back pain without training to stabilize core muscles. 2 0 obj You can download these examples in PDF format here (click on image). PT assessed progress as follows: Increase of 4 degrees R hip flexion, 3 degrees hip abduction and 2 degrees in extension post ther ex when compared to previous session. At In Touch EMR, we charge a flat fee per licensed clinician (no hidden fees or surprises) and it includes everything, unlimited claims and notes and infinite custom template creation. Use of this and other APTA websites constitutes acceptance of our Terms & Conditions. When treating patients, use shorthand to take quick personal notes about your interactions and observations. Sign Up for a FREE Physical Therapy / Occupational Therapy Documentation Cheat Sheet!! 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. Inhibit 3. Patient instructed in green TB exercises for chest fly, shoulder abd, shoulder flexion, elbow flex and extension 215. Patient stated, wow Im really out of shape, but with education on energy conservation techniques, was able to complete the task. Words/phrases that help document skilled care are listed below. 26 N. Beach St., Suite A Inexperienced drivers. 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. In supine, patient positioned properly to train in posterior pelvic tilts, abdominal crunches 2x 15. <>/Metadata 2040 0 R/ViewerPreferences 2041 0 R>> Basically,you want to show the reviewer that you are using your professional skills to teach/train the patient and the caregivers/staff,with your skills,which no one else could teach. Maintenance therapy requires the skill of the therapist to keep a patient at, or slow the patient's departure from their current level of function. 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. Jimmo, Data collection is the foundation for monitoring progress, but, in itself is a daunting task. Overall, patient completed x 15 minutes with PT directing patient with interval training of grading resistance 1-2 minutes. Patient will be seen by a PT and/or PTA 2x per week for 6 weeks under the diagnosis of Left knee OA s/p L TKA and will be reassessed every 7-10 visits for progress. By using this site, you are consenting to our use of cookies. See a certified medical, financial, or legal professional for advice. Privacy Policy | Website Supported by Paradox Marketing, Harmony Healthcare International (HHI) Blog, Maintenance Therapy: Top 10 Things to Know, Compliance Audits/Analysis Reimbursement/Regulatory , Join us November 2nd & 3rd, 2017 atFoxwoods Resort forharmony17, 2023 Harmony Healthcare International, Inc. (HHI). Patient arrived at OT for engagement in incontinence management including PMEs to reduce urinary urgency. The patient will maintain _____ degrees AAROM UE to reduce risk of fixed bony contracture. Ormond Beach, FL 32174 Compensatory Strategies What was the mechanism of the injury? 19. Documentation is required at the onset of each episode of physical therapy care and No assistive device used. Patient instructed in L hip exercises to increase L hip ROM/strength for improved balance and overall pain reduction. At the end of the day, providers must defend their treatment decisions to CMS by offering proof of medical necessity. Patient will require further training to ensure I, recall, and overall competence with HEP prior to discharge. Documentation of discharge or discontinuation shall include the following elements: o Current physical/functional status. Standing: mini squats x 10, hip abduction x 10 bilaterally, hamstring curls x 15 bilaterally, step up to 3 step x 10 alternating LE. 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). All handwritten entries shall be made in ink and will include original signatures. Examples might include cognitive restructuring within CBT or relaxation techniques as part of a mindfulness training program. Patient was limited by pain and fatigue, but with encouragement and stabilization, improvement and tolerance noted. 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 &. Examples of skilled maintenance services include: Establishment of a maintenance plan of care. Assistants are able to provide Skilled Maintenance Therapy to Medicare Part A residents in the SNF. Integumentary: Surgical incision noted along midline of left knee. The clinical gap between where the patient is right now, and where they need to be, is used to create short term and long-term goals. In Touch EMR is one of the only EMR vendors in the rehabilitation space to pass all the 2014 Edition EHR Certification criteria required to satisfy the Base EHR Definition as stated by the Office of the National Coordinator for Health Information Technology, as listed here: http://www.healthit.gov/sites/default/files/pdf/BaseEHR_8-18-12_Final.pdf. This creates a vicious cycle where wedocument too much. When the treatment is expected to result in significant therapeutic improvement over a clearly defined period of time. This is the foundation for the creation of the claim, and reimbursements. Patient is at risk for INITIAL EXAMINATION/EVALUATION Tim Fraticelli is a Physical Therapist, Certified Financial Planner and founder of PTProgress.com. The aims of manual therapy include modulating pain; increasing range of motion (ROM); reducing or eliminating soft tissue inflammation; inducing relaxation; improving contractile and non-contractile tissue repair, extensibility, and/or stability; facilitating movement; and improving function. Therapy, All rights reserved. To make your life easier, we have taken the time to analyze various documentation systems. : educated pt for at home safety w/ emphasis on _________to improve (I) and return to PLOF. Tim Fraticelli is a Physical Therapist, Certified Financial Planner and founder of PTProgress.com. You worked hard to earn your degree. Patient arrived at therapy with 3/10 L hip pain. Whether we like it or not, we have to document, and clinical documentation of skilled services can be time consuming. Review documentation for clinical observation and assessment, management of evaluation of care plan, teaching and training, skilled rehabilitation. Required max verbal cues, tactile cues and visual demo to reduce compensatory strategies. Verbal/visual/tactile cues for increased recall, problem solving, sequencing or overall technique. When considering how to approach setting goals for a patient receiving maintenance therapy delivered by a clinician, analyze the at-risk behavior or decline that would result from a lack of skilled intervention. It can also be the cause of major headaches, rushed lunch hours, and excessive typing throughout the day. The patient will maintain ambulation to 250 feet without loss of balance or shortness of breath utilizing [devise or type of strategy i.e. T - Thoughtfully share challenges and how OT can help push through. The patient reports the surgery was performed with no issues. 10 minutes Neuromuscular Re-education (97112): Weight shifting on balance pad 320 seconds, Rhomberg stance on pad 320 seconds with one UE support, semi tandem stance with perturbations from therapist 21 min., rocker board for proprioceptive training x 3 min. All contents 2023 American Physical Therapy Association. It also means keeping record of your sessions and of your client's progress note, or lack thereof. %PDF-1.5 % The patient will maintain the ability to perform toilet transfers at moderate assist level to prevent deterioration due to Parkinsons disease with significant intention tremors. Examples of Skilled and Unskilled Documentation Treatment Notes Motor Speech Goal: Improve speech intelligibility of functional phrases to 50% with minimal verbal cues from listener. Review these best practices for documentation to help you provide quality care, increase reimbursement, decrease denied claims, and articulate the distinct value of occupational therapy. By end of session, patient stated, I have noticed I am able to hold it in longer.. The fear is What if I dont document correctly?. While there's no special code or modifier to indicate whether a therapy service is considered maintenance care or rehabilitative care, your documentation must clearly state when services are intended to maintain the patient's function. Patient educated on purpose and instructed in Codmans exercise x 1-minute x 5 RUE clockwise, then counter clockwise. Pt instructed in posterior pelvic tilts 310 with 3 sec hold. 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. In Touch EMR is on the Certified Health IT Product List (CHPL) website. Able to mimic after visual demo with good execution. Patient reporting 3 episodes of nocturia increasing risks of falls. This means that your documentation should: Explain your reasons for choosing group therapy, including in each patient's plan of care explicit justification for choosing group therapy as an adjunct to individual or concurrent therapy.
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