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....

This is why taking students is the best! My fabulous OT student created this “nuts and bolts” board for our clients to help improve fine motor coordination skills.

The board is super easy to make. She had a nice man at Lowe’s help her put holes in the board. Then she put all different sized screws in the board. We instruct our clients to unscrew the bolts. To challenge our clients, we may time them.

This client has a difficult time with in hand manipulation and pinching. He told us he’s handy and likes working with tools so this was a very client-centered activity.

OT is so much more fun and rewarding when you engage your clients in meaningful activities.

Do you discharge a patient when they are no longer making progress or have reached their maximum rehab potential?

If you answered yes (which a lot of people do so don’t feel bad) make sure to keep reading.

That is not the appropriate time to discharge and you are doing your patient and yourself a disservice.

Your patient has the RIGHT to have therapy for as long as the therapy is SKILLED!

In Jimmo vs. Sebelius it was established that patients may continue to be eligible for rehabilitation services to progress, maintain or prevent deterioration of functional gains as long as it requires the SKILL of a therapist.

This does not mean that we keep our patients on forever but it also means you CANNOT discharge them because they have reached their rehab potential.

Instead we can only discharge them when they have stopped requiring the skill of a therapist. If a caregiver can do it then it is no longer skilled. (And it does not matter if they actually have a caregiver….it just...

During an initial evaluation it is very important you document skilled care and make sure you take notes of all your patients deficits and safety concerns.

There a few things I do during every evaluation and I have them listed below.

And for your reference I do Medicare Part B so outpatient in the home and assisted livings. So if you do home care this will be different. If you work in an outpatient clinic, however, you should include all of the below as well.

• Reason for the referral to PT. Note if it was because of one or more of these things:
  • hospitalization
  • recent fall
  • pain
  • difficulty walking
  • decrease in balance
  • functional decline
  • injury
  • surgery
• Medications
• Past Medical history
• Falls in the last year
• Hospitalizations in the last 4 months
• Precautions such as:
  • decreased awareness
  • fall risk
  • allergies
  • medical conditions
  • etc (anything to watch out for)
• Pain level
• Vitals
• About living environment (house/apartment, stairs, bathroom situation, if lives alone or with family,...

Communication and Dementia

When I first started working as an occupational therapist, I had a difficult time working with client’s with dementia.  It is A LOT different learning about dementia in school versus actually working with real people who have dementia.  I never realized how much more time and effort it took to engage my client's with dementia. 

About a month into working, I was fortunate enough to attend a dementia seminar where I learned so much valuable information I was actually able to use in my practice.  One of the pieces of information I learned and that I still hold with me today is the 90 second rule.

 90 Second Rule

Client’s with dementia process things much slower than us, which many clinicians may forget or realize.  The 90 second rule states that people with dementia may take up to 90 seconds to process information. For example, if you ask Mr. Smith “can you stand up from the chair?” he may take...

Motivating Difficulty Clients

Do you have those clients that REALLY need therapy, however, they insist they don’t and refuse to come to sessions?

We have a lot : )

But to help improve participation and motivation we make it fun! It’s no longer “therapy” but a dance party!

This client loves baseball so we put on Take Me Out to the Ball Game and had fun dancing.

We danced without upper extremity support. We got down low. We kicked our feet. We sidestepped. We back stepped. We grapevined.

Remember therapy doesn’t always have to be structured...it doesn’t have to be just sets and reps.

Throw on some music and see what balance and coordination activities you can do.

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...

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...

Upgrading Ambulation

Instead of simply ambulating with this client, we wanted to add another component. In order to upgrade the activity, we placed her in the parallel bars and instructed her to walk forward while pushing the therapy ball.

• We put a mirror in front of her for visual cues.
• We dual tasked with ambulation and pushing the ball.
• We provided verbal cues for forward progression while pushing the ball.
• Tactile cues were provided for weight shifting and to increase step length.
• Tactile and verbal cues were used for correct posture.

So what do you think??? Are you going to try this activity??

And by the way this client will be 100 in 11 days!!!

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!

To view our clinical favorites...

Initial Evaluation

Working with older adults is rewarding but can also be challenging.  Often times we get a referral from a client’s doctor for PT or OT services for generalized weakness or gait abnormality.  Some clients we work with often have limited insight into his/her deficits, reporting “I do everything on my own” or “I haven’t fallen.”  Although they may actually be able to get dressed, walk down the hall, toilet, etc themselves, they may present with decreased safety awareness, shortness of breath or take more time to perform these activities.

Applying Our Skill

This is where our skill comes into play. Along with functional outcome measurements, we must analyze each component of the task he/she is performing and use our clinical judgment to determine the appropriate plan of care. Does the client reach for walls or furniture when ambulating throughout their living environment?  Do they have trouble reaching for items?...

Ordering a Wheelchair

When obtaining a wheelchair for your client, there are a few important items that are necessary to include in your note:

• Face to face exam
  • To document this: client was evaluated for mobility needs
• What causes mobility limitations
  • To document this: Client has mobility issues secondary to diagnosis of COPD, CHF and hip and knee osteoarthritis
• What activities of daily living our compromised - document: Diagnosis prevent client from going from her room to the dining room to eat and to the bathroom to toilet
• Is client capable of self propelling and is she willing to use wheelchair. Determining factor is UE strength which needs to be MMT > - document: Client has UE strength of and is able to and willing to self propel a wheelchair
• What activities will be resolved using wheelchair (ex eating, bathing, toileting, grooming, dressing)
  • To document this: Use of wheelchair will allow client to go from bedroom to kitchen to eat and to bathroom to toilet.
• ...