Most physical, occupational and speech therapists went to
school to treat patients, not to become expert documenters. However, Medicare is now performing an
increasingly large number of audits or all types which have caused therapists
to have to expand their documentation skills.
Meeting all Medicare documentation requirements can be a daunting task
and most therapists would rather spend their time treating patients instead of
learning the art of good documentation.
That is why we developed the Blue Sky Institute at Blue Sky
Therapy. The Institute not only provides
continuing education at no charge to our employees and our facilities, but we
also provide an extensive Documentation Program.
The 4 main components of our Documentation Program are:
We begin our process with the simple act of auditing charts. Our
therapists perform peer audits on each others’ charts every month. This process not only helps identify any
issues of concern, but also serves as a learning tool for the therapist. The act of auditing a chart serves as a
monthly reminder of how documentation should look, and what the important
aspect of documenting are. In addition
we have a quality assurance auditing team consisting of several experienced
therapists who perform a more thorough auditing procedure. Each of our facilities has a QA audit at
least once a quarter.
Once we perform the audits we can get a feel for any issues of
concern. We then need to communicate these
areas and what changes need to be made to the therapists. This is where the Blue Sky Institute comes
into play. In 2011 Blue Sky introduced
“Blue Dog Documentation” which is our initiative to improve the documentation
skills of our therapists. Extensive
education on good documentation began including providing tips and samples of
good documentation. We also provide
annual webinars on documentation for CEU credit for our therapists. The webinars are based on an overview of
current trends and industry demands as well as issues found in the audits. In addition, Blue Dog throws our therapists a
weekly “biscuit” which is an email tip sent out regarding proper
documentation. We have an online
training website where new employees can log onto if they missed the annual
webinar and view it there. The website
also offers videos of therapists performing functional assessments tests on
actual patients demonstrating how to perform the tests in a timely and
efficient manner. Each facility is also
provided with a documentation manual which contains samples of all types of
documentation (evaluations, progress reports, re-certifications, daily notes
and discharge summaries) for all 3 disciplines and for several patient types
including cardiac, CHF, incontinence, dementia ACL level 1-2, dementia SCL
level 3 and dementia ACL level 4. This
allows the therapists to see an sample of good documentation for each of these
areas to use as a reference or to stimulate ideas for good documentation.
When issues of concern are identified and
unable to be resolved through the above education, then one on-one-training is
provided by our Quality Assurance/Program Development Team.
Each month 2 employees are nominated for our Blue Sky Employee Documentation
Recognition Program. There is a drawing
at the end of the month and the winner gets a Blue Sky Strength for Life
t-shirt. The program demonstrates to
all of our therapists how our excellent documenters can manage the task of
treating and documenting with excellence.
When issues occur that are beyond the scope of
the above procedures, action plans are developed and if necessary, disciplinary
action taken. We have found taking this
step to be uncommon due to the above proactive process which typically stops
the problems before they get to this point.
Blue Sky is pleased to say that with the above
process in place, our overall quality of documentation has improved
significantly over the last few years.
And just in time too with the manual medical review and increase in
auditing done this year! With the
proper education and support, quality therapists can quickly become quality
documenters as well.