How to document for rehabilitation work objectively
Shelly Mesure, MS, OTR/L
As the scrutiny continues to increase on rehabilitation documentation, finding ways to document objectively has become a major focus for just about everyone involved.
Do you remember the class about uniform terminology? Skilled language is part of the key of documenting objectively. While the industry uses these uniform terms, clinicians of every background continue to create their own acronyms and abbreviations. If a reviewer doesn't translate correctly, the claim could easily be denied.
I love teaching my seminars when we discuss objective documentation. Utilizing industry standard tools is very valuable. However, may only cover a portion of the patient's overall goals. Objective measurements are the key to demonstrating progress; however, uniform definitions don't fit every term.
For example, if I raise my arm 180 degrees over my head, every therapist should agree that my shoulder flexion/extension range of motion is within normal limits (WNL). If I raise my arm to only 90 degrees, everyone should agree that my shoulder range of motion is impaired (IMP). That is pretty easy to determine because range of motion is clearly defined between WNL, WFL (within functional limits) and IMP statements.
However, if I attempt to use WNL for dynamic standing balance activities, what's the difference between WNL, WFL, or IMP? There are no clearly defined boundaries.
When using standard terms, it may be standard in measuring some tasks, but it might not always apply across the board to all areas.
Clear-cut, objective measurements are always the same in every situation. For example, time is a great use for measurement. How long to tolerate an activity? How long to complete the task? How much less time to complete ADLs?
The term “objective” is interpreted as “without bias.” So, when writing your therapy documentation, from evaluations, goals, progress notes, and discharge summaries … have you used skilled terminology to reflect the skills of a therapist/assistant AND used objective terminology and measurements? Think about it.
Shelly Mesure ("Measure"), MS, OTR/L, is the senior vice president of Orchestrall Rehab Solutions and owner of A Mesured Solution Inc., a rehabilitation management consultancy with clients nationwide. A former corporate and program director for major long-term care providers, she is a much sought after speaker and writer on therapy and reimbursement issues.