Overview
This lecture continues the discussion on clinical documentation, focusing on progress reports, re-evaluations, discharge summaries, and the importance of compliance with payer and regulatory requirements.
Purposes of Documentation
- Documentation demonstrates patient progress, justifies the need for skilled care, and supports billing and compliance.
- Each episode of care requires clear records of goals, progress, and ongoing needs.
Progress Reports
- Progress reports are periodic updates on patient status and goal attainment, often required every 10 visits in outpatient settings.
- Reports must address each set goal, justify continued care, and are only completed by physical therapists.
- Repeating outcome measures in progress reports is recommended to show progress.
Re-examination and Re-evaluation
- Continuous patient assessment occurs at every visit, but formal, billable re-evaluations are done for major status changes or lack of progress.
- State laws and payer requirements may dictate the frequency of re-evaluations.
- Re-evaluations include repeating outcome measures, reviewing medical history, performing new tests, and updating or modifying the plan of care.
- Only physical therapists perform and bill for re-evaluations.
Discharge Documentation
- Discharge summaries conclude an episode of care and are completed by physical therapists.
- They summarize goal attainment, repeat outcome measures, and assess medical necessity.
- Discharge includes a self-management plan or referral to other resources as needed.
- Use "discharge" when care is completed or transferred, "discontinuation" if the patient chooses to stop before goals are met.
Letters of Medical Necessity
- These letters justify the need for additional services or special equipment, such as costly wheelchairs or extended therapy.
- They are written as needed, usually for insurance approval.
Addressing Patient Discontinuation
- If a patient fails to complete therapy, write a discharge summary documenting progress, discontinuation, communication attempts, and notify relevant providers if appropriate.
Key Terms & Definitions
- Progress Report — Periodic report on patient improvement and goal status, required by some payers.
- Re-evaluation — Formal reassessment of a patient due to significant changes, requiring a new plan of care.
- Discharge — Completion of an episode of care with summary documentation.
- Discontinuation — Patient ends therapy before goals are met by their choice.
- Letter of Medical Necessity — Written justification for special services or equipment.
Action Items / Next Steps
- Review your state practice act and payer policies on documentation frequency and requirements.
- Practice writing progress reports, re-evaluations, and discharge summaries.
- Ensure outcome measures are repeated and documented at appropriate points in care.