Every patient has a story. We know this as we develop a rapport with our patients and learn more about them, their interests and desires, frustrations and setbacks.
Our driving force is the positive intrinsic values we gain from knowing that we are making a difference in our patients’ lives. Our patients’ outcomes and rehab potential largely depend on their motivation and removing the barriers to rehab. It’s important to document using skilled terminology and technical language, but what’s the point of all of the treatment interventions and plan of care?
I think we need to include our patient’s stories and personal statements as often as possible in all aspects of documentation. If you can put a face and personality behind your justification for therapy services, it not only adds the personal touch, but it makes the documentation more relatable.
I’ve received comments from various claim reviewers and even administrative law judges (ALJs) that when they found out more about the patient’s background, prior level of function and motivation/personal goals, it helped them put the rehab into perspective as to why it was so valuable and important.
So tell their story. Include statements in the evaluations, progress reports, daily notes, discharge summaries and everything else in between.
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 veteran speaker and writer on therapy and reimbursement issues.