Documenting the Same Activity Over Time

It is easy to get into to the same routine sometimes and repeat the same activities over and over again.  To Medicare, this type of routine in our treatment notes becomes unskilled and something that can be facilitated by a caregiver.

Even if your client has a cognitive decline or other impairment that requires repetition, we still need to document OUR skill.

Documenting Your Skill

In order to show skill while having our clients perform similar activities over the course of his/her treatment, some things to document are:  

• Changing cues
• Decreasing assistance levels
• Reps and sets
• Response to treatment
  • RPE
  • Vital signs
• Body position
  • supine
  • sit 
  • stand
• Level of support
  • BUE support
  • UUE support
  • No UE support)
• Upgrades/downgrades

If the activity will help your client to achieve his/her goals then it is important to show why they require the skilled of an OT or PT and not passed onto a caregiver.  

Example: Weight Shifting

• Start with anterior weight shifting with BUE support on parallel bars, 3x10 reps with rest break to monitor vitals 2* SOB
• Progress to no UE support, RPE 6
• Decreased physical assistance on pelvic girdle, min A for postural adjustments
• Progressed activity to adding functional reach with anterior weight shift, intermittent UUE support
• Upgraded position to narrow base of support, client able to perform 9 reps without LOB

Although I am having the client perform essentially the same activity, I am documenting my skill each time and demonstrating progression.

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