Documenting Skilled Care in Your Daily Treatment Notes

Documenting Skill Under TE/TA

A lot of our treatment sessions are billed under therapeutic exercise and therapeutic activities.  In order to demonstrate skilled care, you must be able to justify that these activities/exercises could not be performed by a caregiver.  We have mentioned this before, but regardless of whether or not your client has a caregiver, you must always document skilled care.

Comments To Make

When making comments in a treatment note regarding TE/TA - try to focus the comment on:

• What you as the clinician did to make the activity skilled
• Facilitation techniques
• Inhibitory techniques
• Degree of perturbations
• A specific cue you provided
• The client's response to the activity
• Reps prior to fatigue
• Borg/RPE
• Vital signs
• How you progressed the activity
• Increased step height
• Decreased UE support
• Increased reaching distance
• Standing vs sitting

There is no need to fear audits or discharge a client early as long as you are always showing skilled care.   Some clients need more time based on their diagnosis and co-morbidities. And guess what? You CAN increase the duration of treatment as long as you are changing the way you treat your client and showing that change in your documentation.

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And if you haven't yet, make sure to download our FREE PDF with skilled care documentation tips HERE!

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