Creating Therapy Discharge Summaries: A Time Saving Shortcut for Therapists!
A contract therapy client in Ohio asked the following question …"What documents do you suggest be completed upon discharge? We love the Goals Summary but you have to do a Progress Report to get the up-to-date status upon discharge. We also have to complete the Discharge Summary. The Discharge Summary cannot stand alone as it does not meet the LCD/NCD guidelines without a roll-up of progress towards goals. It's a lot of work to make sure we are compliant. Can you recommend any shortcuts to reduce the amount of time needed to create these documents?"
Our response is as follows … Mary Gennerman, OTR/L, our Director of Clinical Services, researched CMS’s requirements for discharge documentation. She did confirm that our documentation is fully compliant with NCD as defined. Based on her analysis and your desire to find an easier way to document discharges, we recommend a shortcut for discharge documentation as follows …
Create a “Final” Progress Report which can be used in lieu of our Discharge Summary. Discontinue the use of our free standing Discharge Summary. Other clients use this approach which is supported in the literature below. Specifically, “Where the physician writes a Discharge Summary that meets the requirements of the provider setting, a separate discharge note written by a therapist is not required. The discharge note shall be a Progress Report written by a clinician, and shall cover the reporting period from the last Progress Report to the date of discharge.”
The Progress field of the Current Report Status section of the Progress Report can be used to document the "final" status of each goal right up to the discharge date. The Education, Assessment, Plan/Justification, and Anticipated Discharge sections can be used to summarize outcomes, the discharge plan, instructions for continuing care at home, and any other information necessary for discharge. You will no longer display final statements in the Functional Assessment or Measurable Data sections that appear on the Discharge Summary.
The flexibility of our Progress Report allows you to adapt selected document fields thus eliminating the need for a free standing Discharge Summary. Library entries specific to discharge issues can be added for these document fields so a "Final" Progress Report can be customized quickly for discharge documentation.
CarePoint therapy management software takes a “total compliance” approach with respect to documentation required by CMS. Other products may not provide the flexibility that CMS allows. Our system design, data testing, and client input created a documentation system that allows “patient centered” care and does not force “canned” documentation. Our clients can review and manage all aspects of patient care. Our system will notify them if anything is a concern or out of compliance.