How to Make Skilled Care Easier

To make documenting skilled care easier and more efficient think of it like you are telling a story. A story that has a problem then a twist and then the result.

So for this patient her major goal is being able to ambulate without assist again.

Her biggest problem with ambulation is coordination. She is ok when ambulating on a straight path in silence but when when turning she tangles her legs up and loses her balance (she has fallen many times doing this.) And she also loses her balance during dual tasking.

So we started with ambulation and documented the skilled care required. We then focused the rest of the treatment on those deficits. Everything we did that day went back to her ambulation deficits.

And then in the assessment I summed up her deficits. Why the activities were performed. And how she responded to treatment. Also any hindrances that occurred to why she needs further work in these areas.

Some of the Activities Performed 

• Cone...

Progress Note Reporting

When updating your client’s progress in his/her progress note, it is important to justify the need for providing continued skilled care.  This requires you to write a STRONG assessment statement.

Here, you should update:

• The gains your client has made since the initial evaluation or last progress report
• The hindrances to their rate of recovery and ways you are addressing the hindrances.  
  • Make sure these hindrances are varied from progress note to progress note.
  • Also, you need to vary the plan to address hindrances to support continued medical necessity.

Assessment Statement

In your assessment statement, there should be a functional focus on continued care as well as documenting what will be addressed to achieve the goal.  If your client needs continued care due to poor carry over with safety techniques, you may document, “continued skilled OT required for adaptive equipment training and progression of balance activities in...

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...

Justifying Skilled Care With Ambulation

To continue to see our patients and get paid we need to document skilled care. Just ambulating with a patient is NOT skilled care.

And providing the same cues every time is NOT skilled care.

So how do we show our skill:

• Educate patient and caregiver on safety and technique with rolling walker (RW) including staying close to RW and extending hips and knees
• Provide tactile cues at scapula for posture and verbal cues for patient to look straight ahead
• Provide visual cues with a mirror in order for patient to self correct
• Patient reported a 5/10 on RPE scale after ambulating 1000 ft (was 7/10 last week)
• Patient ambulated decreased distance today secondary to reports of fatigue. Vitals accessed and normal. Nursing (or caregiver) aware.

Remember if the only cue your patient requires is to increase heel strike (or whatever the 1 cue is you always provide)  that can be given to a caregiver and therefore is no longer skilled (Medicare does not...

DOCUMENTING HINDRANCES

This patient has a significant fear of falling.

She is just starting therapy and is very hesitant to progress to more advanced balance activities secondary to fear of falling caused by a recent fall.

But that is ok as long as we address this fear and take steps to resolve it.

Throughout my notes I document her fear of falling and I document what I am doing to address it such as:

• Educating patient on fall prevention techniques
• Educating her caregiver on fall prevention strategies to implement with her
• Beginning with B/L UE support and progressing to 1 UE support or no UE support as she gained confidence
• Showing increased balance activities to improve patient's confidence in her balance.
• Encouraging her that her fear is valid but that we will work through it together
• Gaining a good relationship with her so that she trusts me and will progress activities.

I document this throughout her treatment sessions and then will document this at time of the progress...

Fall Prevention

If you work with older adults, it is no secret that most falls can be prevented.  In order to keep your clients living in their homes or senior living communities, it is our job to help reduce a client’s falls risk.  Fall prevention requires a multifaceted approach. As PTs, we help to promote LE strengthening, facilitate dynamic standing balance and improve their overall physical performance.   The OT practitioner will assess the client’s environment and make appropriate modifications, educate caregivers on safe techniques, and assess the need for equipment.

Falling While Reaching

One of the most frequent causes of falls that we see is from trying to retrieve something that is out of reach.  An easy solution to this problem is to use a long handled reacher. We recommend all of our clients have a reacher, or multiple reachers, to place throughout their home.  Common places a reacher may be necessary is in the kitchen,...

Card Matching With Trunk Rotation

This is a great activity for many things including unsupported balance. Trunk rotation. Visual scanning. Cognition.

We had card boards on 2 different tables and this patient had to match the cards.

The tables were set at a 90 degree angle so he had to rotate and remember to scan all visual fields.

When documenting I will normally focus on 1 aspect. So if I’m really working on balance that day I will justify if he losing his balance. If he ever required single or double UE support. If he required stepping to maintain balance. Any education I provided on fall prevention techniques.

If I was working more on vision I would note if he was neglecting a side. How many cues he required to scan.

For cognition I would note if any difficulty matching the numbers or colors. If he required extra time for this activity. If he was able to stay on task.

Do you know other therapists that could use more ideas for client-centered treatment? Make sure to share...

DOES YOUR PATIENT HAVE A HINDRANCE TO RATE OF RECOVERY? WHAT IS IT? WHAT ARE YOU DOING ABOUT IT? DOCUMENT IT!!!

One of the best ways to document the need for skilled care is to document all your patients hindrances to recovery and what you are doing to address it.

I have been seeing this patient for awhile and we have been working on ambulation. Progress has been slow but she still requires the skill of a PT.

The hindrance to rate of recovery that I addressed today was her lower extremity swelling.

I documented increased swelling B/L LE’s and that causing increased pain in her feet from her shoes being too tight.

To work on this I changed the patient’s shoes and educated the caregiver about the importance of well fitting shoes.

I also talked to nursing (if you are in a home it can be a child or POA) about my concern and what they are doing to address it such as how the patient has been evaluated by the doctor and medical intervention is being done to address this.

I...

Many of our clients have difficulty performing housework and other ADL tasks. They are often limited by decreased strength, standing balance, and endurance during these activities.  To keep clients engaged and interested in our interventions, we often incorporate housework into treatment.

Our role as OT’s is to work individually with clients to restore function, teach compensation strategies, adapt the environment or activity to facilitate independence, and promote health. Sometimes we educate our clients on adaptive strategies for performing tasks related to laundry. For example, using a rolling push basket or sitting down while folding clothing to compensate for decreased endurance and promote energy conservation.

If you treat in a therapy gym, it is easy to skip over functional activities.  In order to keep function in our treatments, we make sure to have the right tools with us.  This basket was purchased at the Dollar Tree along with some towels, socks,...

Ball Toss and Talk

I came upon this ball when I was looking through the activity closet of the assisted living facility I work in.  I asked if I could borrow the ball and have used it in many of my treatment sessions. Written on the ball are various talking points including “donut toppings, cities in California, and popular food combinations.”

I like this activity for clients who have a mild cognitive deficit who I am also working on improving balance with.  You can upgrade the activity by having your client stand on a balance pad or add wrist weights. You can easily make your own conversation ball by adding numbered stickers to the ball and then listing different topics numbered on a seperate sheet of paper to reference.  

Therapy equipment can be expensive, but there are also a lot of cheap tools out there to help you build your “tool box.”  I love going to the dollar store, dollar section from Target, and Five Below to look for new...