CarePoint Therapy Management Blog

Daily Therapy Notes: Write High Quality EMR’s Fast & Easy

  

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CarePoint’s Clinical Staff Responds …..

Authored by Mary L. Gennerman, OTR/L, Director of Clinical Services

Documentation reviewers, often LPN’s, scan documents for weekly functional therapy progress such as, “Pt now able to do x, y, and z.”  If there is no significant increase in function for two weeks, they may deny the claim.  A reviewer has 15 to 20 minutes to perform an initial review of each case, which includes a comparison of therapy and nursing notes.

Reviewers scan Daily Notes but they cannot read them all.  They look for entries that relate to the level of progress achieved.  Comments on the equipment used or the number of repetitions performed is not required if it does not affects the Plan of Care.  The Progress Report is used to document the necessity and appropriateness of ongoing therapy services provided.

In our experience, extensive Daily Note entries will create problems upon review.

Examples of actual problem note entries we have seen in the past include …..

• Be brief.  State "Pt performed exercises with the Omnicycle and red theraband” more simply as, “resistive BLE / BUE.”   All exercises fall under 97110 Therapeutic Exercises. There is no need to note them unless they differ from the Plan of Care.

• Exclude unrelated references to a patient’s one time verbal outburst.  If a patient’s behavior is interrupting therapy, it needs to be documented and nursing needs to be notified.  If such behavioral outbursts are reported by several departments, then a psychiatric evaluation should be requested and documented.

• OT documented WC Management as an approach in the POC without identifying any goals, treatments, or referencing the prior week’s Progress Report.  No entries on WC Management were made in Daily Notes or Progress Notes.

• Avoid general non-skilled statements like, “PT discussed POC & philosophy of PT with Pt."

The Progress Report is used to document the medical necessity for skilled intervention.  Properly worded functional short-term goals that clearly measure up to two week’s of patient progress will protect you from denials.  Daily Notes should include only “key indicators” for the Progress Report.  Our Daily Note format shows a patient’s history for the week at a glance for easy review.

Therapy Documentation Made Easy …..

CarePoint’s Documentation system provides the optimum balance of exceptional flexibility plus highly automated tools.  Document each patient's progress using a flexible format of library entries and free form text entries.  Our unique "Document Copy" function reduces document preparation time and improves document quality.  Changes can be made "on the fly" to ensures that all of the documents for each patient are consistent and will stand up to review in all cases.