How to Document Skilled Care When Ambulating With Patients
Skilled Care Documentation
Remember, when documenting your treatment sessions, you NEED to show why what you are doing with your client CANNOT be given to a caregiver.
Changing Cues
To do that, the cues given each treatment sessions need to change. If you are telling your client to increase hip flexion every visit, that is no longer skilled and can be passed on to a caregiver.
Medicare does not care if your client actually has a caregiver or not. So just documenting no caregiver available to provide cues will not justify skilled care!
Documenting Ambulation
Different ways to document your care each visit include:
- Used a mirror for visual cues for upright posture
- Provided verbal cues to ambulate closer to the rolling walker
- Tactile cues provided at hip flexor to increase step height
- Moderate physical assist required when turning the corner
Other tips to document skilled care:
- Include any hindrances and what you are doing to work on them such as client with COPD requiring education on breathing techniques to increase ambulation distance. Also document vital signs during this treatment
- Did you upgrade the activity
- Did you downgrade the activity
- How did your client react and how did that modify the rest of the treatment
- Did you educate a caregiver on any part of this task
Do you know other therapists that could use more ideas for client-centered treatment? Make sure to share this post and follow us and tag them on Instagram www.instagram.com/thenoteninjas
And if you haven't yet, make sure to download our FREE PDF with skilled care documentation tips HERE!
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