Tips for Skilled Documentation
• Be Specific!
o Document specific joint mobility, specific muscle or muscle group strength, specific movement disorders or tone. Connect these specific deficits to function!
§ “Patient has decreased R grip strength (3/5) resulting in difficulty managing her rollator and securing the hand brakes, placing the patient at increased risk for falls.”
§ “Patient has B quad strength of 3+/5 resulting in a need for mod assist with sit-to-stand” o Document the specific task completed, not the general description
§ Donning button-down shirt vs. UB dressing or dressing
§ Clothing management for toileting vs. toileting
§ Dorsiflexion for toe clearance during gait training vs. gait training or ambulation
§ Sequencing tasks for safe use of rollator vs. cognitive training to improve sequencing
• Document what, why, and how o What – What was done during the treatment session? What did the resident do – describe performance skills? What did the therapist do? What did caregivers do (if training was provided)?
o Why – Why did the therapist choose the particular treatment technique? Why were changes or adjustments made in the treatment technique or activity? Why is the activity important to this particular resident? This is often more skilled than the technique or activity itself.
o How – How were the treatment techniques or activities done? How did they address the resident’s goals or help the resident progress towards his/her goals? How did the resident respond to the treatment provided?
• Document objective data o Standardized tests & Outcome measures
§ PT – Tinetti, Berg, Dynamic Gait Index, Braden Scale, mini BEST, TUG, Ashworth, 1 Rep Max, Wong Baker Faces pain scale, PRE scale, 6-minute Walk Test
§ OT – Allen Cognitive Level Screen (ACLS), Functional Reach, Modified Barthel, Katz ADL, Lawton IADL, Rancho Los Amigos Scale
§ ST – RIPA-G, MOCA, NOMS, SLUMS, Mann Assessment of Swallowing Ability o Vitals (O2, HR, Respirations, etc.) o Comparative data (start vs. interim/end scores)
• Document why the services require the skills of a therapist and cannot be safely or effectively performed by a CNA, family member, or caregiver
• Skilled vs. Unskilled Terms o Skilled – techniques, strategies, analyzing, return demonstration, establishing, modifying, compensatory strategies, implementing, graded cueing, educate, assess, measure, progressing, improving, carryover, facilitate
o Unskilled – generalized weakness, chronic condition, good/fair/poor, monitored, slight improvement, slow progress, routine, repetitious documentation (even good documentation loses its effectiveness when copied several days in a row), refusals, unable to learn, lack of carryover, unresponsive
• Functional Goals o Short Term Goals should be functional and achievable in 1-2 weeks. If STGs are not met by week 3, they should be modified or a reasonable explanation given.
o Long Term Goals should reflect the anticipated discharge status (i.e., stairs at home, community mobility, showers, taking care of others, etc).
o Goals reflecting Underlying Impairments (ROM, strength, etc) may be used as STGs as long as we have other functional goals that they relate to.
o Goals must be upgraded/discharged as they are met. Current status should not exceed the goal level. Goals can be upgraded even if only a portion of the goal is met (i.e., goal to be min A with UB dressing in unsupported sitting, achieved min A in supported sitting > can upgrade to CGA in supported or unsupported sitting). o It is ok to downgrade a goal if it is no longer appropriate. Document the reason for the downgrade in the body of the note.