Written By: Kathy Boyarko, PT, CDP, Program Development Manager
One of the best ways to justify therapy services with long term care residents who have demonstrated a functional decline is to have nursing documentation supporting the patient’s decline or issues. Often time’s nurses may verbally tell you of a concern or decline when you screen the patient, but they have not documented it in their notes. For an auditor, when this happens, it can appear as though the therapist is picking the patient up for therapy services unnecessarily.
The solution to this problem is NOT to fail to pick the patient up for therapy, it is to assist and encourage the nurses to document the decline in their notes.
If you do not already have a process for this in your facility, here are some guidelines to get you started.
First, make sure to have the rehab manager discuss the topic in morning meeting. Be sure to explain that in order to avoid denial of payment for therapy services, nurses supporting documentation is needed. Show them the nurses documentation request form and explain that you will be giving it to them when you wish to pick up a resident for therapy. If you fail to introduce this and explain it, and then go and ask a nurse to give you supporting documentation, they will not likely understand what you need and why.
Medicare strongly recommends at least 3 days worth of supporting documentation in the nurse’s notes to justify therapy. However there are a few exceptions to this, particularly when safety is involved. For example-- if a patient has a fall or is noted by nursing to be choking on their food. In these instances, the resident should be evaluated right away for their safety.
In other cases where there is no immediate safety demand, the procedure is:
- Nursing identifies a need for therapy or the therapist identifies a need through their screening.
- Begin whatever process you normally use to obtain a physicians order, unless you have standing orders.
- Complete a nurse’s documentation request form. Blue Sky Therapy provides our therapists with a quick and easy form to complete and give to the nursing staff to remind them to make sure that the reported decline in functional status is documented in the nurses notes.
- In 3 days, verify that the nurses have documented something regarding the decline and that you have an order and if so, go ahead and evaluate the patient.
Sometimes a nurse does not feel comfortable documenting a decline that an aide verbally told you about and the aides may not perform any documentation in the chart. If this is the case, explain to the nurse that you are not asking them to document that they saw a decline if they didn’t, you are simply asking them to document that the aide stated that they noticed a decline. This should reassure them and make them more comfortable.