“Don’t put that in your mouth!”
“Don’t put your finger in there!”
“Do you even know where that has been?”
Since we were just tiny infants we have continuously been told things to avoid. The fact that I have written this, and you are here reading it tells me we have both been relatively good avoiding the most dangerous things we were told not to do throughout life. Like that time I decided to listen when being told, “If I’ve told once, I’ve told you a hundred times! Stop climbing that tree with your favorite metal rod during the lightening storm!”. Everywhere we go there are caution signs, stop signs, warning signs. Social media is full of things that we can’t or shouldn’t do. Without some regulations and rules life would be full of chaos.
The world of physical and occupational therapy is no different. We are all aware that healthcare is full of regulations. It seems like there are more regulations each year. When all we want to do is what is best for the patient. It can seem like the frustration is endless. I wish that I could make all the frustration go away. I may not be able to eliminate the need for documentation and high productivity standards; but I can share with you some specific things to avoid in your daily clinical documentation.
Adhering to the following recommendations can improve how your notes demonstrate a need for skilled care. Just like listening to your Mom when she told “don’t put that fork in the electrical socket!” kept you from getting electrocuted; avoiding these phrases can also help reduce the chance the care you provide gets stopped early due to denials of care.
Top 7 Phrases to Avoid Using In Your Clinical Documentation
- Sport Specific” – Sport specific training is not covered by general health plans or Medicare. If they are well enough to do sport training, it is time to discharge care from their health benefits (great opportunity to continue as cash pay though). This would include training like specific drills for the particular sport, golf, baseball or tennis swing training, throwing progressions, Olympic lifting training, etc on an ongoing basis. Assessing these things once or twice to help establish a HEP and discharge may be acceptable though. The focus should be on functional training and exercise to get them back to regular daily tasks. Your documentation should concentrate on things like walking, stairs, driving, lifting for work or chores, ability to care for self or family, ability to change direction, balance, overhead use and more. All too often I see goals and abilities that only reflect the final sport or recreation the person will be doing (LTG #2: pt will return to full soccer participation with team). Then come to find in a phone call for more information the patient is still on crutches and having trouble with stairs; but the provider listed their progress as a percentage of their sport ability (LTG #2: progressing, pt at 50%).
- “PT/OT is necessary per MD Rx” – The MD may have given a recommendation on the patient having therapy, but it is your responsibility to show the need for your skills by identifying the functional problems that therapy will address. Document those functional problems. Who is the PT/OT here, you or the MD?
- “Patient is improving slowly but surely.” – Given enough time and self effort, most people will improve regardless of getting therapy. Skilled care should cause significant and measurable progress in a reasonable amount of time (think 4-6 week periods). They should improve due to care, not in spite of it. What I have seen in my work with clinical review is that this statement is most often used in documentation where no real measurements and outcomes are being used. The provider has to grasp at thin air to get something down that looks like the patient is improving. A much stronger method of showing progress would be to use your measures in a statement about their progress: pt has shown progress through a 10 pnt change in the BERG scale from 32 to 42 and has increased walking distance from 100 ft min A to 250 fit min. Even better, if you have these measures in a table you can just say “patient significant progress shown in objectives table”.
- “Continue PT/OT as patient is not able to do HEP” – Not being able to complete a home program is not a reason to continue using a skilled care benefit (Especially with Medicare) especially when the care becomes repetitious or is something a caregiver could be trained to do. If they can’t do it, then other accommodations need to be made with family or caregivers.
- “Patient requires continued PT due to pain” – As odd as it may sound, most skilled care benefits (including Medicare) are not for the care of pain alone. The benefit is there to improve function. They may have pain, but medical need should be shown through functional deficits that are improving with care. Pain can be part of the equation, but can’t be the only part.
- “Patient is a fall risk.” – Using just this phrase alone is a no-no. So be sure to quantify that fall risk (and continued improvement) with the appropriate functional measures that demonstrate a fall risk. This is another very common oversight that I see in PT/OT clinical documentation. I get it, trying to get various measures at appropriate intervals can be hard to track. Yet, I would say that we have all been trained very well to make the BEST assessments we can. This includes supporting assessments with actual data. In addition, if the fall risk is not improving, accommodation with assistive devices may be more appropriate than continuing skilled care.
- “Patient requires continued manual therapy” – There is nothing to show that manual therapy is superior in causing a patient to improve functionality over other therapy options. Manual therapy certainly has its place. Especially during the acute phases of care. One could certainly argue that Manual therapy is never “required” for a patient to improve. Focus on the patient’s progress, not your manual therapy prowess.
Skilled Care vs. Maintenance Care Resource
I created this simple guide to help me better understand the differences between skilled care and maintenance care. Before I had it I always felt lost trying to decide if care was rehabilitative or the care was more appropriate as maintenance care. I know this reference will help you understand them better. I recommend you keep the included chart near where ever you do your documentation.
Two Bonus Phrases To Use With Caution
- “Provided verbal and tactile cuing.” – This phrase is often thrown into clinical notes without additional context. Just because you give cues it does not mean they were needed. What cues were given in relation to what decreased function? Are those functions shown to be deficient through an actual measure? I could “cue” Lionel Messi in how to approach and kick a football (soccer ball), but does he really need that?
- “Patient requires care to return to sport participation” – General health insurance does not cover sport training. Using this phrase makes it sound like the patient has returned to sports, or at the least, can do their normal daily tasks. If using this phrase, be sure to qualify if they still have trouble with daily tasks besides just sports. This is much like the first example I used to start this article.
So there you have it. Seven of the top phrases you should avoid in your physical or occupational therapy documentation. I hope that by reading these you have noticed a bit of a pattern. It is not so much that these phrases are bad. It is what is eliminated when you only use phrases like these. They are vague. The aren’t supported by outcomes or other specific functional measures.
Did you find these phrases helpful? Guess what, I have more!
Would you like 7 more phrases to avoid and two more bonus phrases to use with caution? That’s 18 awesome ideas to help make your documentation defensible and better than ever before. Then look no further than here:
Exclusion List for Rehab Docs v1.0
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Here is my list of common phrases and ideas that should not be used in skilled physical or occupational therapy clinical documentation.
This list contains 18 things you should really think about before putting them in your clinical notes each day.
Each item has a small explanation t…