If you didn’t document it, it didn’t happen. How many times have we all heard those words? Today, I would like for us all to consider not merely the importance of documenting daily skilled care but also the reason for referral and the need for initiating services in the first place.

It would be a critical misstep personally, but also procedurally, for your organization not to do so. That’s why this is a must-know topic.

What occurred medically?

Who noticed the change?

How did it impact function?

All these areas are essential in supporting recommended frequency and duration of care and begin with effective documentation on the therapy specific plan of care.

We know in the realm of skilled nursing facilities, therapists play a crucial role in evaluating and treating residents to optimize their functional abilities and quality of life. Central to this process is the documentation of the reason for referral (RFR), which serves as a roadmap for therapy interventions and guides the interdisciplinary team in providing tailored care. 

Here are essential documentation tips for physical, occupational and speech therapists working in SNFs:

Consider the Where, Who, Why, What, When and How.

Where: Determine the patient’s prior location before arriving at the facility to understand the context of their current condition. If the individual is residing in the SNF as their home, consider how functional declines or improvements impact function in their most natural environment. 

Who: Identify the party requesting the therapy evaluation, whether it’s an MD order from the hospital, nursing staff, family members and loved ones, or from a screen request. 

Why: Clearly articulate the reason for referral, which may stem from a recent medical event such as hospitalization with a decline in function, a fall, aspiration, communication difficulties, or other relevant factors.

What: Describe the functional or potential decline observed in the patient, including deficits in activities of daily living, safety concerns, or impacts to quality of life.

When: Document when the decline in function began; or improvement in function allowing for rehab intervention began to provide a timeline for tracking progress or disease progression.

How: Explain how the medical diagnosis relates to the functional decline, considering the influence of disease processes on deficits and safety issues. Remember medical diagnosis alone doesn’t determine the need for skill, but it helps to paint a story for evidenced based care interventions. 

Additionally, therapists should provide supporting details and examples of how shifts impact function. 

  • Offer specific details and examples about the patient’s condition to support the exacerbation of a chronic medical condition or the need for skilled therapy intervention.
  • Highlight current deficits, safety issues, and factors preventing the patient from returning home independently.
  • Individualize the RFR to the specific patient’s circumstances rather than providing general information that could apply to multiple individuals.

Next, we should tailor the RFR to the patient’s needs:

To accomplish this goal, therapists should ensure that the RFR reflects the individualized needs of the patient, considering their unique functional status, goals, and challenges.

Clearly articulate what occurred that necessitates a skilled therapy evaluation and intervention.

If therapy is sought for a decline in function, specify what tasks the patient is currently unable to perform that they could do independently before the referral.

Finally, consider including a timeline.

For long-term residents, incorporate a timeline of the functional decline or expected progression of the disease process to provide context for therapy interventions.

Document any changes in functional status over time, including improvements or further decline, to inform ongoing care planning and adjustments.

Examples of well-documented RFRs for different therapy disciplines in SNFs illustrate how to effectively convey the patient’s situation and therapy needs:

Physical Therapy (PT)

“Patient admitted to SNF after recent hospitalization for total hip arthroplasty (THA) with referral to PT from hospital discharge (DC) team. Rehabilitation is sought to increase strength and improve transfers/gait for the patient to return home with spouse.”

Occupational Therapy (OT)

“Patient, a long-term care (LTC) resident of the SNF, referred to OT by nursing due to recent decline in activities of daily living (ADLs). Patient now requires increased assistance with dressing, despite being able to dress independently two weeks ago. No specific medical event reported by nursing.”

Speech Therapy (ST)

“Patient, a LTC resident of the SNF, referred to ST services due to new onset of prolonged mastication with solids, pocketing food during meals, and decreased oral/pharyngeal function, posing a risk for aspiration and pneumonia. Limited safety awareness observed.”

In summary, clear documentation of the reason for referral is essential for therapists working in SNFs to ensure targeted and effective interventions that address the individual needs of each resident. By following these documentation tips and providing clear, detailed information, therapists can contribute to improved outcomes and quality of care for SNF residents.

Renee Kinder, MS, CCC-SLP, RAC-CT, serves as the Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she contributes her expertise as a member of the American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, the University of Kentucky College of Medicine community faculty, and an advisor to the American Medical Association’s (AMA) Current Procedural Terminology CPT® Editorial Panel, and a member of the AMA Digital Medicine Payment Advisory Group. For further inquiries, she can be contacted here.

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