Tuesday, July 28, 2015

Preparing for Chart Audit- Documenting Skills of a Therapist

My mom came down for a short visit a few weeks ago. Because it's always a big deal when Grammy comes to visit, we spent the afternoon preparing:  the boys  swept the floors and cleaned the bathrooms, my daughter changed the sheets on the bed and I had straightened up things in the playroom, office and living room. Coby, Jay and Mike put on fresh t-shirts, Meredith  brushed their hair, I dabbed on some lip gloss and my husband was wearing his best baseball cap.  We were looking good...or so I thought.

All of the sudden, I looked at things from my mom's perspective- it was a completely different picture!

Because we were preparing for our trip to Arizona, there was significant disarray:  the kitchen table, bar, living room, dining room, foyer and hallways were stacked high with boxes, bags and totes. There was even a wagon parked in my office! Upstairs in the playroom, the kids sat like zombies, glued to the tv, there were laundry baskets full of clean clothes and someone "accidentally" pulled the curtains down.

Mom didn't have to say a word, but I knew she was thinking, "Oh em gee!"

All I could  say is "Please don't judge me. It's not always like this."

She gave me a very polite smile and a sympathetic pat on the back, "I know."

Maybe this has happened to you... you think you're doing a good job, but when you look at things from someone else's perspective, you realize maybe you're falling short.

Well, that same thing can be true when it comes to the documentation of therapy services.

Let me explain.

One of the agencies I work for requires all therapists to assist with chart auditing. It's just a few hours each year, but it's a great opportunity to look at documentation from a different perspective. Until I participated in this auditing process, I never really knew how evals, recerts and visit notes were being  judged. 

Well, come to find out, there is only one  thing that really matters:  the documentation of the skills of a therapist

To be more specific, Medicare guidelines state that "all therapy services must be medically necessary and be provided at a level of complexity and sophistication that requires a speech-language pathologist to perform the tasks."

So, if you're not writing about the things you do that no one else can do other than you, the therapy professional, you are falling short. An auditor could deny payment on a claim if these things aren't abundantly clear.

Keeping that in mind, I thought I would review some of the components of skilled services...those complex and sophisticated things you do every day that make your job so great.

Here we go! 

15 Activities That Require the Skills of a Therapist

1.  analyze medical and behavioral data
  • complete a thorough chart review
  • obtain past medical history
  • consider physical, social, emotional, cultural influences

2.  evaluate and assess using appropriate tools or protocols
  • select assessment tool
  • administer test
  • score and interpret results

3. determine diagnosis and prognosis
  • assign diagnosis
  • record severity of impairment
  • make a prognostic statement

4.  use terminology that reflects technical knowledge
  • showcase any professional, discipline specific terms
  • incorporate appropriate medical terminology

5.  design plan of care 
  • establish functional short term goals
  • create functional long term goals
  • define criteria for discharge

6.  develop and deliver treatment based on progression of complexity
  • select appropriate materials, activities, strategies, etc.
  • incorporate hierarchical methods for delivery of tasks, cues, etc. 

7. facilitate success
  • modify tasks or activities, as needed
  • provide encouragement or praise, as appropriate
  • share documented progress with patient, family

8. guide practice during selected therapeutic tasks
  • provide demonstration
  • use prompts and cues as needed

9. provide discussion of rationale
  • give information about how the intervention:
    • relates to a functional goal
    • improves safety
    • increases independence

10. use objective data that supports progress toward a goal
  • accuracy of response
  • speed/ latency of response
  • frequency of occurrence
  • number of cues
  • type of cues
  • level of independence
  • physiological changes

11. use feedback
  • verbal
  • visual

12. explain decision making
  • modification of treatment plan
  • change of treatment activities
  • addition of goals or activities

13. provide patient/ caregiver/ family training or education regarding:
  • diagnosis
  • plan of care
  • goals
  • progress
  • barriers to progress
  • strategies, techniques
  • precautions
  • facilitation of carryover and generalization of skills

14. make professional recommendations

  • compensatory techniques
  • safety strategies
  • diet texture
  • liquid viscosity
  • communication alternatives
  • carryover activities

15.evaluate and assess education provided

  • patient, caregivers, family members verbalize understanding
  • patient, caregivers, family are able to return demonstration

Often times, I begin visit notes using the easily identifiable phrase,  Skilled intervention this session included...

Here's an example from a note I wrote last week. In just two sentences, I detailed quite a few activities from the list above that only a therapist could perform:

Skilled intervention this session included: demonstration, instruction and guided practice through various AROM and PROM exercises for increasing oral strength, movement and agility- min visual, verbal and tactile cues; demonstration then guided practice though laryngeal elevation, glottic closure, voicing and deep breathing exercises- min verbal prompts; guided practice through speech production tasks, naming activities and picture description tasks- mod phonemic cues and binary choices;  guided practice with swallow strategies and safety techniques- SLP provided demonstration and min verbal cues. Education was provided to patient and caregiver regarding rationale and functional importance of each speech, language and swallow task- understanding verbalized

Granted, these were two pretty long sentences, but I'm sure you'll agree, there was no question about what I was doing as the SLP to provide skilled intervention during this session. This is not the entire note, and this is not the absolute only way to document your skilled interventions, but...upon review, I'm fairly certain this claim will be paid!

So, this week, as you go about your work, think of exactly what you are doing to offer complex, sophisticated therapeutic skills to your patients, their caregivers and families. Then,  be sure to write it down, because if you don't write it down, it never happened! 

Thanks for reading...have a great week!

We should be rigorous in judging ourselves and gracious in judging others.
John Wesley