Guest Columns

The need for documentation in therapy

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Tara Roberts
Tara Roberts


With all the continued hype around reducing re-hospitalizations especially in the first 30 days post discharge to avoid penalties for hospitals and eventually SNF providers, it may be smart to emphasize therapy efforts and success in preventing a hospital readmission may lay in skilled therapy notes.

Skilled therapy documentation traditionally focuses on prior level of function, current level of function and ultimately desired discharge level of function. Outcomes are typically measured in short and long term spans of time with a focus on a reduction in level of assistance whether physical or verbal and ultimately patient centered goals met as they relate to functional independence.

More important than ever is disease management education and patient ownership in the rehabilitation process. There should be an agreed-upon goal that focuses on the patient's ability to achieve long term self-management of chronic conditions. While this likely has always been part of a therapy treatment plan, less often is it validated in documentation for outcomes:

  • Does the patient understand disease process?
  • Does the patient know and able to stare risk factors and warning signs to report?
  • Does the patient grasp the importance of a continued healthy committed disease management life style?
  • Will the patient likely be compliant or is relapse a likely outcome?
  • Did the resident avoid re-hospitalization during therapy bout?



While SNF providers, rehab specialists and therapy advocacy groups work to continue to collect and organize outcome data that will hopefully influence and shape  a valid Medicare reimbursement program based on traditional measures,  therapy documentation that links patient education and disease management to reduced hospital re-admissions should be sought after and emphasized.

And possibly, another desirable side effect of this type of documentation is better-supported therapy claims. How can reviewers argue with therapy interventions that are linked to reduced recidivism? And the savings are arguably to be profound.

Tara Roberts, PT, is the corporate director of rehabilitation and wound care services at Nexion Health Management, Inc.

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Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.

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