“The pen is mightier than the sword” is an age-old adage that implies that the power of communication — in this case, written communication — is more powerful than a physical weapon. Do you adopt this philosophy when you are sending emails, text messages, or any other type of written communication?
Have you ever thought that it’s easier to communicate by phone or in person to avoid miscommunication that may be perceived from an email or text message? Well, this also applies to our medical records and rehab documentation.
Unfortunately, our only option to clearly communicate our message is through written (or typed) communication. The message to be communicated is how the services provided were medically necessary, relevant to the patient, and an appropriate level of care for the diagnosis, condition, illness, and/or injuries indicated. This message, however, is left widely open for interpretation, and therefore, we now live with the routine process of claim reviews from a variety of agencies.
So, let’s use “power” words to clearly communicate our message and avoid any misunderstanding or “lack of medical necessity.” In my opinion, there are many ways to incorporate power words, but here are just a few suggestions:
1. Safety – anytime you can reference safety as a concern and show the therapeutic interventions to show rehab potential
2. Prevent or slow further decline – with the Jimmo v. Sebelius lawsuit, this recognizes therapy as a major aspect of our clinical practice to work with patients diagnosed with long-term/chronic (or not improving) diseases, conditions, and/or illnesses
3. Medical necessity — instead of documenting, “Skilled PT/OT/SLP for …”, rephrase as “Medically necessary (skilled) PT/OT/SLP for …” It frames the statement or summary to be easily recognizable as the main purpose of the services provided.
I’m sure this list could become very long, but hopefully I’ve been able to get the hamster started running around the wheel in our brains. So, what other POWER words would you add to this list?
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.