Documentation At Its Finest!

Written By: Kathy Boyarko, PT, CDP, Program Development Manager

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:

1.       Auditing

2.      Education

3.      Recognition

4.      Re-audits

Auditing:  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. 

Education:  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.

Recognition:  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.