What is your preferred writing tool?
Pen? Pencil?
Do you take notes in color? Use highlighters?
Or are you really advanced and prefer to type all your notes?
I find myself recently making strange observations of individuals’ preferred writing tools when I am in meetings. Particularly in meetings that require collaboration, brainstorming and development of new ideas.
When I see someone come in a meeting and immediately open his or her computer, I think, “distracted.”
When I see someone reach for the paper — often a pad that is provided by the meeting place or hotel — and a pen, I think, “Oh, goodness, they are going to be interesting.” If you are writing in pen, you might as well be writing in stone. Perhaps this individual is rigid or worse unyielding once an initial idea is given or plan is formed.
And when I see someone pull out lined paper and a No. 2 pencil I think, “BINGO!” He or she is here to collaborate. This is someone who is going to be a team player, open to new opinions and flexible when change is needed.
Along the same line, we as therapists need to consider how our therapy plans are developed and written.
We know that as part of the rehab process we are charged with completing continuous assessment of a patient’s progress as a component of ongoing therapy services and treatment.
Therapy plans, as a result, cannot be written in stone at the start of care. Plans need to be fluid and flexible allowing care to be advanced with ability to adjust and alter in order to meet unique care needs.
How do we document needed changes?
Guidance for making these adjustments can be found in Medicare Benefit Policy Manual Chapter 15 220.3 – Documentation Requirements for Therapy Services.
Following the initially established plan of care, therapists have many options for adjusting the initial plan including documentation in daily treatment notes, progress reports and re-evaluations.
Let’s discuss which changes to treatment, goals and overall plan can be made within each documentation type.
I need to add a new treatment intervention to a plan of care, what changes to treatment can be made within a treatment note?
• If a treatment is added or changed under the direction of a clinician during the treatment days between the progress reports, the change must be recorded and justified on the medical record, either in the treatment note or the progress report, as determined by the policies of the provider/supplier.
• New exercises added or changes made to the exercise program help justify that the services are skilled. For example: The original plan was for therapeutic activities, gait training and neuromuscular re-education. “On Feb. 1, clinician added electrical stim. to address shoulder pain.”
My patient has shown great progress toward our initial short term goals, what changes to goals can be made within a progress report?
• Assessment of improvement, extent of progress (or lack thereof) toward each goal;
• Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions should be documented in the clinician’s progress report; and
• Changes to long- or short-term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment.
This initial treatment plan is not meeting my patient needs, what changes to plan should changes occur via re-evaluation?
• A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services.
• A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation.
• Indications for a re-evaluation include new clinical findings, a significant change in the patient’s condition, or failure to respond to the therapeutic interventions outlined in the plan of care.
In closing, remember to keep it No. 2 pencil style when developing your patient plans. Show them you are here to be team player, here to be open to new opinions and interventions to best serve their needs — and of utmost importance, flexible when change is needed.
Renee Kinder, MS, CCC-SLP, RAC-CT is Director of Clinical Education for Encore Rehabilitation. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).
