1. + Documentation In SNF Setting: Recipe For Success for Documenting Skilled Therapy By Chrissy Van Osdol, OTD OTR/L

2. + Types of Documentation Evaluation Telephone Orders (T.O.) Functional Limitations (G Codes) Reevaluation Weekly Progress Notes Daily Notes Discharge Summary

3. + Evaluation Reason for Referral Data gathered in evaluation process Client factors Assessments & Results Analysis of occupational performance Summary and analysis Discharge planning Recommendations Write T.O. Place eval in chart

4. + Documenting Reason for Referral State source of referral and services requested State specific information including: age, gender, diagnosis State reason therapy is necessary-identify areas of decline or changes in functional capacity Note difference between current skills compared to prior functional status

5. + Evaluation Examples Reason for Referral 1. Pt has declined in strength and endurance. 2. Pt referred for OT evaluation s/p abdominal surgery to remove gallbladder 1. This 54 year old female presents to therapy with impairments in self care for 1 week due to LTHA. The patient has shown a decline from Independent living to Max A in ADLs and IADLs. 2. 84 y/o male who was admitted to the hospital for pneumonia then transferred to CCE for rehab. Pt has diminished abilities to complete ADL's and would benefit from skilled OT tx. Actual Examples Of Non-skilled Documentation Actual Examples of Skilled Documentation

6. + Recipe for success: Reason for Referral- Example 1 Includes the following information: 1. Specific client information including age, gender, diagnosis 2. Source of referral and services requested 3. Reason therapy is necessary- identify areas of decline or changes in functional capacity. Note difference between current skills compared to prior functional status 84 year-old male diagnosed with LTHA and pneumonia referred to this facility by primary MD for skilled OT intervention and treatment. Pt was independent with all ADLs/IADLs and currently demonstrates decreased independence with ADL/IADL performance. Pt will benefit from skilled OT intervention to return to prior level of function. To demonstrate skill : include the following Information Example of Skilled Documentation

7. + Recipe for success: Reason for Referral- Example 2 Includes the following information: 1. Specific client information including age, gender, diagnosis 2. Source of referral and services requested 3. Reason therapy is necessary- identify areas of decline or changes in functional capacity. Note difference between current skills compared to prior functional status 75 year-old female who is a long term resident of this facility was referred for OT skilled evaluation and intervention by house MD Pt presents with a decline in ADLS in the areas of LE dressing and personal hygiene and grooming. Nursing reports a decrease in safety and need for increased assistance. Pt requires skilled therapy in order to improve safety and function. To demonstrate skill : include the following Information Example of Skilled Documentation

8. + Documenting Medical Necessity 1. Choose appropriate medical diagnosis that supports therapy services 2. Identify impairments on the evaluation that require the unique skills of a therapist to address 3. Justify why safe and effective functional improvement requires the skills of a therapist

9. + Evaluation Examples Medical Necessity Skilled therapy is needed to improve function. Exercise and activities to increase pt skills Skilled therapy is necessary to improve functional decline in self care task performance in order to increase independence and safety with ADLS/IADLs, and to decrease caregiver burden. Therapy necessary for increasing endurance and functional activity tolerance to increase independence in self care and work tasks. Without therapy patient at risk for falls, muscle atrophy and decreased ability to care for self. Actual Examples of Non-skilled Documentation Actual Examples of Skilled Documentation

10. + Recipe for success: Documenting Medical Necessity Includes the following information: 1. Choose appropriate medical diagnosis 2. Identify underlying impairments and functional deficit 3. Justify need for the unique skills of a therapist 4. Risks if therapy is not provided 1. Pt has a diagnosis of TBI NOS and demonstrates decreased independence performing ADLs- UE dressing due to decreased UE ROM. Pt. will benefit from skilled OT services to increase UE ROM and decrease risk of contractures. Without OT, pt is at risk for skin breakdown, further loss of independence and increased caregiver burden. To demonstrate skill : include the following Information Example of Skilled Documentation

11. + Documenting Client Factors Includes: 1. Personal health information (PHI) such as: medical history, diagnoses, precautions and contraindications 2. Prior residence and living arrangement 3. Environmental Factors 4. Social support 5. Prognostic indicators

12. + Evaluation examples: Client Factors Prior Residence and Living Arrangement 1. Pt lived Ily 2. Unknown 1. Pt lived in ALF with husband. ALF is one level and has grab bars in the bathroom. Facility provides meals. Pt and husband perform laundry tasks together. Pts husband has medical history of AFIB and has limited ability to help around the house. Pt drives independently. 2. Pt lived independently in single level apartment on the second floor of ALF with an elevator. Pt has a tub/shower combo with grab bars, bath bench and hand held shower. Pt has a FWW for ambulation in the home and community mobility. Pt is driven by others or uses public transportation Actual Examples of Non-skilled Documentation Actual Examples of Skilled Documentation

13. + Evaluation examples: Client Factors Environmental Factors / Social Support 1. Return home 2. Has sister and grandchild in the area. 1. Pt lives at home with his wife and son. Pt's son is an Iraq vet with psychiatric issues, pt reports son is a hoarder and pt does not feel safe at home. Pt does not want to return home with son living in home. 2. Pt has the social support of a son who lives in Portland and can assist pt as needed. Pt is highly motivated to return home to care for her husband and to return to her volunteer activities. Actual Examples of Non-skilled Documentation Actual Examples of Skilled Documentation

14. + Evaluation examples: Client Factors Prognostic Indicators 1. Improvement in medical condition. 2. Motivated 3. Pt lived independently 1. Pt able to follow 2-3 step directions. Pt has strong social support at home 2. Pt is motivated to return to personal home. Pt demonstrates positive results from previous therapy. Actual Examples of Non-skilled Documentation Actual Examples of Skilled Documentation

15. + Evaluation Information also includes: Assessments & Results Include information on specific assessments performed and results Standardized/non-standardized assessments, interviews, chart review, observations Analysis of occupational performance Interpretation of client’s performance skills, performance patterns, contextual and environmental factors, activity demands and outcomes of assessments Summary and analysis Interpretation and summary of data related to areas of concern Comparison of results with previous evaluation results Intervention plan State goals, modalities, anticipated outcomes, and frequency of therapy Recommendations Provide recommendations for intervention and discharge based on all client data, client preference and assistance available after discharge

16. + Evaluation Examples Recommendations & Discharge Planning 1. D/C plans unknown 2. D/C home 1. OT recommends placement with 24-hour assistance for supervision and safety. Patient's husband states discharge location to be determined, may be open to memory care. 2. D/C home with assist and home health to follow vs. ALF Actual Examples of Non-skilled Documentation Actual Examples of Skilled Documentation

17. + Evaluation Examples Functional Limitations – G Code Completed on: 1. Evaluation, 2. Weekly progress notes 3. Discharge summary Measures progress between reporting periods Addresses one area until resolved, such as: self care, other OT primary area, other OT subsequent area Notes percentage of client ability in area based on progress towards goals Performed every 10 th visit Completed only on days that intervention occurs

18. + Steps after the evaluation: Write Telephone Order Write T.O. in chart that includes the following information: Modalities / CPT codes Frequency and duration of treatment Therapist signature and credentials Fold T.O. over diagonally and leave at nurses station so that nursing can call in telephone order to the physician Place evaluation in chart Place completed evaluation in chart within 24 hours of evaluation

19. + Recipe for success: Telephone Orders (T.O.) Includes the following information: 1. “OT Clarification order” 2. Task performed 3. Modalities/CPT codes 4. Frequency 5. Signature of therapist and credentials 1. “OT clarification order. OT evaluation complete and plan of care developed for skilled 1:1 OT intervention to work on therapeutic activities, therapeutic exercises, self care training, physical agent modalities and orthotic management 5wk4” (Signature and credentials) To demonstrate skill : include the following Information Example of Skilled Documentation

20. + Re-evaluation Report (Updated Plan of Care) Client information Document measurable results based on daily and weekly progress notes Reevaluation results Document updated scores from standardized and non- standardized assessments Analysis of occupational performance Document justification for updated POC

21. + Re-evaluation Report Examples (Updated Plan of Care) Justification for Updated POC 1. Goals updated this assessment period 2. Completion of updated plan of care for physician certification. 1. Pt requires continued skilled OT education, intervention and practice to improve independence and safety during ADL and IADL performance 2. Plan of care updated to revise goals based on client improvement in ADL task performance as evidenced by level of assist needed for self care tasks and assessment scores. Actual Examples of Non-Skilled Documentation Actual Examples of Skilled Documentation

22. + Documenting Skilled Services Patient must require the unique skills of a therapist. Document evidence of: 1. Skilled services provided Must be included to demonstrate the specific education and training of an OTR or COTA required to provide therapy services Must indicate specific skills that cannot be provided by a nurse, Restorative Program, caregivers or other healthcare/community providers 2. Response to therapy Must be included to indicate current progress with goals and client factors that address the progress 3. Reason for continuation Must be included to address potential progress towards goals/prognosis for OT intervention 4. Discharge plans Must be included so that goals are related to discharge location

23. + Daily Notes Includes: Interventions used Environmental or task modification Assistive devices or adaptive equipment used Education to client, staff, caregivers Client’s present level of performance Client response

24. + Examples: Daily Notes 1. Assessment of self-care skills resulted in increased functional abilities. 1. OT facilitated therapeutic exercises with pt to promote an increase in UE ROM to perform self care/home care tasks. OT provided education on joint protection strategies through full range of movement with BUE HEP using 2 pound hand cuffs on each arm. Pt performed 1 set of 20 reps with full elbow flexion/extension with verbal cues required for energy conservation/pacing and pursed lip breathing. Pt verbalized and demonstrated understanding of education received. OT will continue to work on progression towards goals. Actual Examples of Non-Skilled Documentation Actual Examples of Skilled Documentation

25. + Recipe for success: Documenting Skilled Intervention in Daily Notes- Example 1 Includes the following information: 1. Skilled service includes: Observation, Assessment, Education, Facilitation or Modification 2. Patient response to therapy 3. Reason for continuation 4. Discharge plans 1. OT facilitated head, trunk and UE/LE movement using proprioceptive neuromuscular facilitation techniques to improve sitting balance and bed mobility. Pt required Max A to sit at edge of bed with verbal, visual and tactile cues required to maintain upright position. Pt will benefit from additional practice and education for goal progression. Pt plans to discharge home with 24 hour care. To demonstrate skill : include the following Information Example of Skilled Documentation

26. + Recipe for success: Documenting Skilled Intervention in Daily Notes- Example 2 Includes the following information: 1. Skilled service includes: Observation, Assessment, Education, Facilitation or Modification 2. Patient response to therapy 3. Reason for continuation 4. Discharge plans 1. OT provided caregiver education for feeding techniques and compensatory strategies to increase pt independence with self feeding. Pt and caregiver required demonstration and practice for correct follow through of strategies provided. Pt and caregiver verbalized and demonstrated understanding and will not require additional education in this area. Pt plans to discharge home with 12 hour assist from caregiver and 12 hour assist from family. To demonstrate skill : include the following Information Example of Skilled Documentation

27. + Recipe for success: Documenting Skilled Intervention in Daily Notes- Example 3 Includes the following information: 1. Skilled service includes: Observation, Assessment, Education, Facilitation or Modification 2. Patient response to therapy 3. Reason for continuation 4. Discharge plans 1. OT modified wheelchair seating to promote improved postural support and increase functional mobility within the facility. Pt required CGA to sit upright in chair with verbal, visual and tactile cues required to sit at 90 degree angle and maintain upright posture. Pt verbalizes and demonstrates understanding of learned strategies. Caregivers will benefit from education for correct body mechanics to increase pt/caregiver safety when providing w/c positioning and assist to pt. Pt plans to remain a long term resident at this facility. To demonstrate skill : include the following Information Example of Skilled Documentation

28. + Weekly Notes Should include: Focus for required skilled services since last report Analysis of functional outcome Skilled services provided since last report Patient/Caregiver training Remaining deficits/underlying impairments Impact on burden of care/daily life Updates to treatment approach Prognosis for further progress

29. + Examples of Weekly Progress Notes: Skilled Services Since Last Report 1. Assessment of self-care skills resulted in increased functional abilities. 1. OT skilled services have included education, demonstration and practice in the areas of therapeutic activities to increase sitting and standing balance and tolerance for functional activity performance; therapeutic exercises to increase UE strength and UE ROM for ADL and IADL task performance; self care training to increase independence with personal hygiene and grooming and LE dressing; orthotic training to increase pt independence for donning/doffing splint. Actual Examples of Non-Skilled Documentation Actual Examples of Skilled Documentation

30. + Recipe for success: Documenting Skilled Services Since Last Report in Weekly Notes- Example 1 Includes the following information: 1. Observation, Assessment, Education, Facilitation or Modification provided by the therapist 2. Indicates specific CPT codes related to the training was provided to address 3. States specific goals addressed related to the CPT codes 1. OT skilled services have included education, demonstration and practice in the areas of therapeutic activities to increase sitting and standing balance and tolerance for functional activity performance; therapeutic exercises to increase UE strength and UE ROM for ADL and IADL task performance; self care training to increase independence with personal hygiene and grooming and LE dressing; orthotic management to increase pt independence for donning/doffing splint. To demonstrate skill : include the following Information Example of Skilled Documentation

31. + Weekly Progress Notes Patient/Caregiver Education Should include: Who provided the education Who was the recipient of the education and training provided Why was the education needed What specific education and training was provided How was the education provided (verbal, visual, tactile, educational materials) What was the result/ response to the education

32. + Weekly Progress Notes Patient/Caregiver Education 1. Provided patient education in techniques to maximize safety and participation in ADL's. 1. OT provided pt education for OT modifications and adaptations to meal preparation task performance to increase pt safety. Education included work simplification, assistive device training, energy conservation/pacing, pursed lip breathing with educational materials provided for MET levels. Pt verbalized and demonstrated understanding but will benefit from additional education and practice. Actual Examples of Non-Skilled Documentation Actual Examples of Skilled Documentation

33. + Recipe for success: Pt / Caregiver Education Includes the following information: 1. Who provided the education 2. Who was the recipient of the education 3. What education was provided 4. Why was the education needed 5. How was the education provided 6. What was the response to the education 7. What additional education is required 1. OT provided education to pt and nursing staff to increase transfer skills with the use of a sliding board and commode during toileting tasks to increase pt and caregiver safety. Education was provided with verbal cues and demonstration with educational materials provided. Pt and nursing staff verbalized understanding, but required extensive verbal and tactile cues during task performance. Pt and nursing staff will benefit from additional education and practice in this area. To demonstrate skill : include the following Information Example of Skilled Documentation

34. + Discharge Summary Summarizes the change in client skills between initial evaluation and discontinuation of services. Includes basic information as included in weekly progress notes Provides recommendations for equipment, discharge location, level of assist needed and referrals for community/home health services States reason for discharge and discharge location

35. + References Clark, G.F., & Youngstrom, M.J., (2008). Guidelines for documentation of occupational therapy. The American Journal of Occupational Therapy, 62(6), 684-90. Pro-Step Rehab. (n.d.) Documentation reminders. Unpublished document. Pro-Step Rehab. (n.d.) Documentation reference guide. Unpublished document.