Documentation: An Opportunity to Advocate for Your Patient

Editor’s note: This text-based course is an edited transcript of the webinar, Documentation: An Opportunity to Advocate for Your Patient, presented by Trisha Salome, PT, DPT.

Learning Outcomes

After this course, participants will be able to:

• Define the ethics of documentation.
• Discuss the need of high skilled documentation.
• Differentiate weak from SMART goals.
• Articulate goal writing in palliative care and maintenance therapy.

Background

Today's agenda begins with an exploration of ethics and their significance. To prepare, we'll tackle the challenging aspect first by engaging in some preliminary reading. Hopefully, starting with the more demanding material will ensure a fresh perspective. Following this, we'll delve into the intricacies of high-skilled documentation. You've likely encountered the adage "painting the picture" before. Allow me to offer my perspective on this concept. We'll dedicate time to discussing how to document your thoughts effectively, the defensibility of documentation, the importance of timeliness, and the necessity of clarity and conciseness. From there, we'll transition into the realm of SMART goals. Additionally, I aim to allocate time to address the complexities of documenting challenging patient cases, the role of maintenance therapy, and adopting a palliative mindset.

Ethics of Documentation

• Principle #1: Physical therapists shall respect the inherent dignity and rights of all individuals.
• Principle #2: Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients and clients.
  • 2C. Physical therapists shall provide the information necessary to allow patients or their surrogates to make informed decisions about physical therapist care or participation in clinical research.
• Principle #3: Physical therapists shall be accountable for making sound, professional judgments.
• Principle #4: Physical therapists shall demonstrate integrity in their relationships with patients and clients, families, colleagues, students, research participants, other health care providers, employers, payers, and the public.
  • 4A. Physical therapists shall provide truthful, accurate, and relevant information and shall not make misleading representations.
• Principle #5: Physical therapists shall fulfill their legal and professional obligations.
• Principle #6: Physical therapists shall enhance their expertise through the lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors.
• Principle #7: Physical therapists shall promote organizational behaviors and business practices that benefit patients, clients and society.
  • 7B. Physical therapists shall seek remuneration as is deserved and reasonable for physical therapist services.
  • 7E. Physical therapists shall be aware of charges and shall ensure that documentation and coding for physical therapist services accurately reflect the nature and extent of the services provided.
• Principle #8: Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, or globally.

We'll start by examining PT ethics as outlined by the American Physical Therapy Association. The first principle underscores the importance of respecting individuals' inherent dignity and rights. Principle two emphasizes that physical therapists should embody traits of trustworthiness and compassion. Delving into 2C, I'd like to highlight the obligation of physical therapists to provide patients or their surrogates with the necessary information to make informed decisions about their care.

Principle three underscores the accountability of patients in making sound judgments. Principle four emphasizes the importance of integrity in various professional relationships, spanning from patients and clients to colleagues, students, and the broader healthcare community. Under this principle, 4A specifies that physical therapists must provide truthful, accurate, and relevant information without resorting to misleading representations. It's evident how documentation is intricately woven into these ethical principles. Documentation naturally emerges as a key aspect when discussing the importance of truthful and accurate information.

Moving forward, principle five underscores the need to fulfill legal and professional obligations, while principle six highlights the imperative of continuous professional development—a journey you're actively pursuing by participating in this class. Congratulations are in order for your commitment to ethical practice.

Principle seven delves into promoting organizational behaviors and business practices that ultimately benefit patients, clients, and society. Let's delve deeper into 7B, which stresses the importance of seeking appropriate remuneration for services rendered. This directly ties into the realm of documentation. Additionally, 7E underscores the necessity for awareness of charges and ensuring that documentation and coding accurately reflect the services provided.

The reason for starting today's session with an exploration of ethics is paramount. Regardless of your initial motivation for enrolling in this class, there's an ethical obligation to be mindful of charges and to ensure that documentation accurately reflects the services rendered. This obligation remains steadfast despite any barriers, time constraints, or workplace limitations that may impede your ability to execute this task effectively. Principle eight underscores the importance of participating in efforts to address local, national, and global health needs.

Documentation serves as the driving force behind treatment decisions, influences coding practices, and directly impacts billing procedures. Every entry in our documentation essentially shapes the course of treatment. Whether we handle the coding ourselves or delegate it to our back-office team, our documentation sets the stage for coding practices. Similarly, regardless of whether we manage billing internally or outsource it, there's an undeniable link between documentation and billing processes. This linkage underscores the ethical dimension inherent in documentation practices.

The connection from documentation to billing is not merely transactional—it's imbued with ethical considerations. This interplay highlights the importance of ethics in documentation practices. Cantu's article specifically examines documentation within skilled nursing facilities. It raises a poignant observation: the current Medicare reimbursement system tends to prioritize the quantity of rehabilitation services over their quality—a reality familiar to us all.

Cantu suggests that clinicians and administrators should engage in open, honest dialogue to navigate the delicate balance between organizational goals and clinical ethics. Acknowledging the complexities involved, it becomes evident that fostering transparency and dialogue is essential in addressing these challenges effectively.

The significance of understanding medical necessity lies in its pivotal role in determining coverage by health insurance providers based on your communication or documentation. Essentially, medical necessity refers to health care services or supplies required for diagnosing or treating an illness, injury, condition, disease, or its associated symptoms, all of which adhere to accepted medical standards.

Let's get into the specifics of how the Centers for Medicare & Medicaid Services (CMS) defines medical necessity. It is crucial for us to grasp CMS's precise definition of this concept. The definition provided directly by CMS underscores the importance of documentation in substantiating the need for skilled care.

CMS states: Documentation to Support Skilled Care Determinations (Rev. 179, Issued: 01 - 14 - 14, Effective: 01 - 07 - 14, Implementation: 01 - 07 - 14) Claims for skilled care coverage need to include sufficient documentation to enable a reviewer to determine whether — Skilled involvement is required for the services in question to be furnished safely and effectively; and The services themselves are, in fact, reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The documentation must also show that the services are appropriate in terms of duration and quantity, and that the services promote the documented therapeutic goals. Such determinations would be made from the perspective of the patient’s condition when the services were ordered and what was, at that time, reasonably expected to be appropriate treatment for the illness or injury. Thus, when a service appears reasonable and necessary from that perspective, it would not then be appropriate to deny the service retrospectively merely because the goals of treatment have not yet been achieved. However, suppose it becomes apparent at some point that the goal set for the patient is no longer a reasonable one. In that case, the treatment goal should be promptly and appropriately modified to reflect this. The patient should then be reassessed to determine whether the treatment goal, as revised, continues to require the provision of skilled services.

Existence of Medical Necessity Example

Let's focus on a key point here. According to CMS, the documentation must demonstrate that the services provided were appropriate in terms of duration. It's crucial to recognize that the existence of a functional limitation alone does not automatically establish medical necessity for physical therapy services. Rather, it's the documentation of this functional limitation that aligns with CMS's definition of medical necessity for these services.

This distinction underscores the importance of accurate and comprehensive documentation in justifying the need for physical therapy interventions. When I initially encountered CMS's definition, it compelled me to share this knowledge with you through today's education session.

To reiterate, merely identifying a functional limitation is not sufficient to justify the necessity of physical therapy services. It's the thorough documentation of this limitation that aligns with CMS's criteria for medical necessity. Hence, today's education aims to equip us with the tools to advocate effectively for our patients, ensuring they receive the services they require.

Your documentation essentially bridges your patient's healthcare needs and the payment approval for the services deemed medically necessary. Consider this from the patient's standpoint: Imagine a patient arriving at the outpatient clinic seeking relief for chronic back pain. It's crucial to understand that the determination of medical necessity for their care hinges not solely on the presence of a functional limitation but rather on the tests chosen, the critical thinking applied, the professional judgment exercised, and the level of detail articulated in your documentation.

In essence, the comprehensive and well-articulated documentation plays a pivotal role in demonstrating the necessity of the care provided. This underscores the importance of thorough and accurate documentation practices in ensuring that patients receive the care they need while also facilitating the approval of payment for those services by insurance providers.

How Do We Document?

Effectively documenting the existence of a medical condition and meeting the criteria for medical necessity while fulfilling our ethical obligations can be achieved through various methods and technologies.

In the past, we relied on traditional documentation formats such as SOAP notes (Subjective, Objective, Assessment, Plan), daily progress notes, flow charts with check boxes, and paper charts. Even in outpatient settings, some may still use Word documents for documentation purposes.

However, with the advent of electronic health records (EHRs), we now have access to more advanced documentation systems. Smart charting features and data scrubbers analyze our documentation, providing suggestions and enhancing accuracy. Additionally, the integration of artificial intelligence (AI) into documentation processes opens up new possibilities for efficient and insightful documentation.

Looking ahead, the future of documentation holds even more potential. Imagine a scenario where documentation occurs through observation via cameras or verbal interactions with patients wearing wearable devices that capture movement data. This exciting prospect hints at a future where documentation becomes even more detailed and comprehensive, potentially capturing nuances and insights that were previously overlooked.

In essence, the possibilities for the future of documentation are limitless, driven by advancements in technology and an ongoing commitment to meeting ethical obligations and ensuring the highest standards of patient care.

High Skilled Documentation

Today's primary focus will be high-skilled documentation, covering various platforms without delving into specific software. I'll assume that you can navigate a wide range of documentation tools. Rather than focusing extensively on daily notes, I'll prioritize discussing the assessment aspect of documentation, although I'll touch on documenting progress briefly. While I won't delve deeply into documenting from an AI perspective, the excitement surrounding AI advancements in our field and their possibilities for the future is worth noting.

In high-skilled documentation, the quality of your documentation is directly linked to the quality of your assessment. It's essential that your assessment is evidence-based and utilizes appropriate standardized tests. While this course isn't solely focused on evidence-based practice, here are some of our favorite evidence-based standardized assessments. They include the Five Times Sit Stand, Berg Balance Test, Timed Up and Go (TUG), Six-Minute Walk Test, Pediatric Evaluation of Disability Inventory - Computer Adaptive Test (PEDI-CAT), Neck Disability Index (NDI), Pelvic Floor Assessments, One Repetition Maximum (1RM), and many more. Some considerations include ease of use, reliability, validity, and relevance to the patient population. I find the Five Times Sit Stand particularly useful in home health and outpatient settings.

Some electronic health records have prebuilt tests that are not great, have low levels of evidence, are not good for my patient population, or are not recommended by coworkers. Participants often report some tests and measures are not as effective or appropriate for their clinical practice. These include AM-PAC, 6-Clicks, FOTO (particularly noted for being time-consuming), Modified Rankin for stroke, Oseretsky (deemed too vague), and Tinetti.

While there may not necessarily be inherently "bad" tests, it's important to consider factors such as the level of evidence supporting a test, its suitability for the patient population, and its practicality in clinical settings. Additionally, concerns were raised about the misuse or inappropriate application of certain tests and the importance of ensuring correct test positioning, particularly in manual muscle testing. Any test can become problematic if used on the wrong population for which it was tested. This underscores the importance of careful consideration and critical evaluation when selecting tests and measures for assessment purposes.

It's important to reiterate that this course is not focused on evidence-based practice or standardized testing methodologies. There are dedicated resources available for those topics. Instead, our focus today is on the critical link between your assessment's quality and your documentation's quality. This course is not intended to instruct on performing an assessment or selecting specific tests for evaluation. Rather, we aim to explore effective documentation practices and strategies for advocating for your patients through thorough and accurate documentation.

By understanding the pivotal role that documentation plays in conveying your assessment results and advocating for appropriate care, we aim to enhance our skills in documenting effectively to support our patients' needs.

Back to Basics

Let's delve into the intricacies of documentation and advocacy for our patients and return to basics. Let's ensure we cover all the essential aspects, including obtaining a thorough background and past medical history and understanding what occurred with the patient before they arrived at our facility. This encompasses details such as previous surgeries, physical therapy treatments, and any prior chiropractic care they may have received.

We must also ascertain their diagnoses and medication history, as these can provide valuable insights. It's important to compile a comprehensive list of diagnoses and explore any additional health issues beyond their current presentation. Assessing their prior level of function is crucial; we need to discern if their current condition is typical for them and gather information on the duration and usage of any assistive devices they rely on.

Consideration of the discharge environment is essential, particularly if the patient is not being treated in an outpatient setting. What are their goals for their next level of care, and what transition needs will they have upon leaving our care? We must anticipate what they will require to progress to the next phase of their rehabilitation.

In essence, just as a basketball player must remember the fundamentals of dribbling, physical therapists must remain diligent in attending to these basic yet critical aspects of patient assessment and care.

Painting the Picture

Regarding documentation, we often hear the phrase "painting the picture," emphasizing the importance of including detailed information and specific numbers. It's not just about counting repetitions or measuring distances; it's about capturing the nuances of a patient's progress and challenges.

Consider the difference between these two statements: "Patient stood for 30 seconds without assisted device on a flat surface with moderate assistance" and "Patient required moderate assistance to regain balance and prevent falls three times during a static balance activity of standing without assisted device on a flat surface."

Let's break down the first example: "Patient stood for 30 seconds without an assisted device on a flat surface with moderate assistance." In this scenario, the patient required moderate assistance to maintain balance and prevent falls three times during a static balance activity.

While the first statement highlights the patient's ability to stand for a specific duration with moderate assistance, the second statement adds depth by specifying the context of the activity and the number of times assistance was needed to prevent falls. This additional detail paints a clearer picture of the patient's progress and challenges.

By quantifying the instances of assistance needed, whether it's one, two, or three times, we can effectively demonstrate changes over time and track progress between visits. This nuanced approach to documentation allows us to articulate subtle improvements and justify continued treatment with greater precision and clarity.

This level of detail is crucial, especially when conveying subtle improvements or changes in a patient's condition. Without it, it can be difficult to articulate progress and justify the need for continued treatment to insurance providers. So, let's remember the importance of painting a detailed picture with our documentation to effectively advocate for our patients and demonstrate the value of our interventions.

In the next example, I opted for a more detailed approach instead of simply stating, "patient tolerated exercise well," which lacks specificity. For instance, I wrote, "Patient tolerated exercises well with some rests." Even this provides a clearer picture, indicating that while the patient managed the exercises, they needed occasional breaks.

However, to enhance the description further, I wrote, "Patient required rest between exercises with noted shortness of breath." This conveys a more accurate representation of the patient's experience during the session. But to truly paint a vivid picture, I added, "Patient required rest between exercises with noticeable shortness of breath, as evidenced by an increased respiratory rate from 12 to 24 breaths per minute." This detailed description highlights the need for rest and the presence of shortness of breath and quantifies the change in respiratory rate, providing tangible evidence of the patient's condition.

We can precisely demonstrate the patient's progress or challenges by including specific numerical values, such as the increase in respiratory rate from 12 to 24 breaths per minute. Additionally, specifying the duration of rest needed further enriches the documentation, providing a comprehensive portrayal of the patient's response to treatment and facilitating a more accurate assessment of progress over time.

Documenting Your Thoughts

• Don’t assume the reader will know what you are thinking
• Document as if you are explaining what has happened with the patient to a student
• Explain the correlation from response to treatment to modification to the treatment plan
• If you were to be on the phone with the insurance company, what would you tell them about the patient to justify ongoing care? Document that!

A valuable lesson I learned early in my career was the importance of documenting my thoughts and reasoning behind patient care decisions. This epiphany occurred when I was responsible for mentoring a student after just one year as a physical therapist. Teaching someone else forced me to scrutinize my documentation practices. I realized that the information I conveyed to my student needed to be captured in my documentation. As I explained the correlation between patient response to treatment and modifications to the treatment plan, I recognized the potential for more robust documentation.

Further insight came when I had to advocate for additional visits with insurance companies. Frustrated by their reluctance to approve, I articulated detailed justifications for ongoing care. I realized the rationale I presented to insurance companies should also be documented. If I could effectively communicate the patient's needs over the phone, I should be documenting that rationale for continued care.

Taking on a student revealed to me the gaps in my documentation practices. Recognizing the need for improvement, I made a concerted effort to enhance the thoroughness and clarity of my documentation. Through these experiences, I learned that documenting not only serves as a record of patient care but also as a means of communicating my clinical reasoning and advocating for my patients' needs.

Risk Management and Denial Management

The pivotal moment that transformed my approach to documentation occurred soon after my student completed her time with me. I received a subpoena to appear in court regarding a document I had prepared just before her arrival. I was apprehensive because I knew I hadn't been the most diligent documenter. When the attorney from my office instructed me to read from my documentation, I realized the gravity of the situation. However, upon reviewing the chart, I found myself struggling to recall the details of the case. It wasn't a patient I had worked with extensively, and I couldn't fathom why the case was headed to court.

During the deposition, the attorney advised me to express uncertainty and defer to my documentation when necessary. Following his guidance, I repeatedly stated, "I'm not sure. I need to refer to my documentation." Surprisingly, my deposition concluded without the need to appear in court. Nevertheless, the experience profoundly impacted me and fundamentally changed how I approached documentation.

Defensible Documentation

This incident and my experience mentoring a student led me to understand the critical importance of risk management and denial management in documentation. I realized that my documentation serves as the primary means to defend the care I provide and advocate for my patient's needs, especially when dealing with insurance companies. The notion of "documenting as if your documentation is going to court" resonated deeply with me. It underscored the need to paint a comprehensive picture with my documentation, capturing the patient's condition and my clinical reasoning and intentions.

Ultimately, I recognized that as a physical therapist, I am the primary advocate for my patients, and my documentation plays a crucial role in safeguarding their interests. Retroactive denials can have detrimental effects on patients and influence future policies. As highlighted by Ecler et al., "There is nothing more frustrating than not receiving recognition for the work performed...Insurance payers do not recognize the work due to suboptimal documentation."

Therefore, I resolved to approach documentation with the utmost diligence and attention to detail, ensuring that I effectively communicate the needs and progress of my patients while mitigating potential risks.  You work hard, and we should get credit for that work. Your patients deserve care, and you should get paid for the great care you provide. 

Document Skill

It's essential to document the unique skills and contributions of the therapist during patient visits, clarifying why their presence was indispensable. Often, documentation solely focuses on the patient's actions, such as walking or performing exercises, overlooking the therapist's role and the rationale behind their involvement, including why someone else couldn't have done your part. This oversight undermines the clarity and comprehensiveness of patient records.

Considerations such as why the therapist's expertise was necessary and why a caregiver couldn't perform the same tasks should be addressed. Detailing the therapist's actions during the visit and the rationale for their presence helps justify their role in the treatment process.

Timely Documentation

Furthermore, timely documentation is crucial for maintaining accuracy and clarity in patient records. The last time I was treating patients in an outpatient clinic, I decided to do a mini-personal study when I was busy and when I was not. I timed myself doing documentation over the course of time and at various times during the day. This study revealed that point-of-care documentation was significantly more efficient, averaging about eight minutes. In contrast, documentation at lunchtime took approximately 11 minutes, and end-of-day documentation, when rushed due to busyness, averaged 16 minutes. Delayed documentation resulted in decreased accuracy, lost details, and increased potential for patient confusion. Despite common objections regarding time constraints, documenting at the point of care is faster and yields higher detail levels.

Clear and Concise

A clear and concise documentation style enhances efficiency and improves readability and comprehension. Avoid over-documenting, as verbosity can obscure crucial details within a lengthy narrative. While details are vital, they can easily get buried in excessive text.

Limiting abbreviations is key to maintaining clarity and reducing ambiguity. For instance, distinguishing between "heart rate" and "handrail," both abbreviated as "HR," or "wound care," and "wheelchair," both as "WC," prevents confusion and ensures accurate interpretation.

In non-electronic documentation, legibility is paramount. Ensure that your handwriting is clear and easily decipherable, minimizing the risk of misinterpretation or errors. In summary, prioritize clear and concise documentation to streamline communication, enhance comprehension, and maintain accuracy in patient records.

SMART Goal Writing

In the upcoming section on SMART goals, I invite you to select a patient you've treated and remember well. This patient could be your favorite, least favorite, most memorable, or the most challenging case you've encountered. The key is to choose someone about whom you recall numerous details. If you don't have writing materials handy, please take a moment to gather paper, a pen, or any other writing device, as we'll be engaging in an exercise together. This will allow you to actively participate and apply the concepts we'll discuss to your own clinical experiences.

• Specific: State exactly what you want to accomplish (Who, What, Where, and Why)
• Measurable: How will you demonstrate and evaluate the extent to which the goal has been met?
• Achievable: Stretch and challenging goals within the ability to achieve outcomes. What is the action-oriented verb?
• Relevant: How does the goal tie into your key responsibilities? How is it aligned to objectives?
• Time-Bound: Set 1 or more target dates, the “by when” to guide your goal to successful and timely completion (include deadlines, dates, and frequency)

On your paper, let's create a SMART goal for your patient. Whether you're familiar with the SMART goal acronym or not, we'll delve into it today. We'll aim to deepen your understanding if you're already acquainted with it. As therapists, we often incorporate some elements of SMART goals, but not consistently all.

Firstly, let's ensure our goal is Specific. This means clearly stating what you want to accomplish, including who is involved, what actions are needed, where it will occur, and why it's important. Next, we'll ensure it's Measurable. This entails defining how progress will be assessed and determining when the goal has been achieved. Moving on to Achievable, we want the goal to challenge the patient while remaining within their capability to accomplish it. We'll then consider the action-oriented verb—what specific action will the patient take? Next, we'll examine how Relevant the goal is to your key responsibilities and whether it aligns with your objectives. Lastly, we'll ensure the goal is Time-bound by setting one or more target dates for achievement. Let's walk through each of these components together to craft a robust SMART goal for your patient.

Specific

Let's begin with Specific. This step is all about being strategic. What exactly are you trying to accomplish with your patient? Take a moment to write down the acronym SMART on your paper—S-M-A-R-T. For the "S" in SMART, consider what you're trying to achieve for your patient. Write exactly what you want to accomplish with them and why it's important. Remember, make sure your goal is specific to the needs and circumstances of your selected patient.

Measurable

Moving on to Measurable. How will you know when you have achieved the goal you've set? Consider the intended outcome. Make sure you can measure what you're aiming to achieve. Take a moment to revisit your goal and ask yourself: How will I measure progress towards this goal? Can I quantify the outcome in some way? Ensure that what you're aiming for is not overly subjective. Your goal should be clear and quantifiable. 

Achievable

Now let's consider Achievable. Remember the mantra: challenging but not impossible. Your goal should require skilled intervention, which cannot be achieved through the normal recovery course alone. Ensure that what you've written so far meets the criteria: it's specific, measurable, and achievable. Additionally, confirm that it's challenging but not beyond reach and that it requires your expertise. What action-oriented verb will you use to drive this goal forward? Take a moment to review and refine your goal, ensuring it meets these criteria.

Relevant

Now, let's focus on Relevant. How does our goal tie into our key responsibilities? Is it aligned with our objectives? We must ensure that our goal is relevant to the patient's needs. Consider the patient's health condition, body structure and function, activities, participation, personal factors, and environmental factors. Relevance is key here. Our goal should directly address the patient's specific situation and needs, particularly regarding activities and participation. Take some time to reflect on the relevance of your goal to the patient's unique circumstances.

Time-Bound

Now, let's focus on being Time-bound. You need to set a target date or specify the number of weeks needed to achieve your goal. Consider the timeframe within which you expect the goal to be achieved. Some settings may have predetermined timeframes, such as a marking period in schools, one week, until discharge, 30 days, or the certification period in home health. Others can be adjusted as needed. Ensure that your goal has a clear deadline or timeframe associated with it. Is your goal time-bound? Review your goal to ensure it includes a specific timeframe for achievement, aligning with your patient's needs and your setting's requirements.

Now, take a moment to review your SMART goal and ensure that it is specific, measurable, achievable, relevant, and time-bound. Check that it includes the necessary elements and aligns with your patient's needs and the setting's requirements.

SMART or Not So Smart?

1. Patient will ambulate 50' with single hand-hold assist on even surface without losing balance in 1 month to walk his daughter down the aisle.
2. The patient will increase strength from 3/5 to 4/5 in the bilateral lower extremity (B LE).

Let's assess each aspect of these goals to see if they are SMART.

Is the first goal specific? Yes. Is the second one specific? Yes. Is the first goal measurable? Yes. Is the second one measurable? Yes. Is the first goal achievable? We may lack sufficient information to determine that based on what I've provided. The same applies to the second. We've addressed relevance by stating "to." Now, for time-bound: to walk his daughter down the aisle, there's likely a specific date in mind. However, we've omitted that detail. The first goal is smarter than the second. For the second goal, the patient might need to achieve four out of five strength in bilateral lower extremities. However, we're missing a specific time period and its relevance to him. While it might be relevant, we've overlooked that aspect.

1. The patient will sit up on the edge of the bed.
2. The patient will tolerate upright sitting balance as evidenced by maintaining oxygen saturation at or above 95%, no complaints of increased shortness of breath, or increased respiratory rate by more than four breaths a minute for 20 minutes within 30 days to decrease the risk for respiratory infection and to enjoy bird watching.

Let's do another example. Is the first goal specific? Yes. Is it measurable? You might be able to measure that. It is potentially achievable. Is it relevant and time-bound?

The second one is extremely specific and measurable. You might not have enough information to determine if that's achievable. Is it relevant? To decrease the risk of respiratory infection and enjoy birdwatching. It is time-bound since it says within 30 days. If you are an insurance company, which one of these two seems to require skill? I think it's important to use a different lens. Which one seems as though you're advocating for your patient? In another breath, which one, if you're communicating with the family, seems important? Which one, if you're communicating to nursing staff, seems important? Which one, if you're communicating to the physician, seems important? Which one, if you catch the patient on a bad day, seems to be one you could engage the patient on? I can tell you I did not follow my rule of conciseness on the second one. Hopefully, you can see the difference between this goal and the second goal. 

Difficult Progress Measuring Situations

What is the most difficult patient to document? A patient with no stated goal, a patient without a likelihood of improvement, or a patient with no desire to participate in treatment? Most people feel like it is a patient with no desire to participate in treatment. Many things are difficult to document. We are going to spend some time talking about that now.

Setting Specific

The change in setting certainly alters your documentation requirements, whether in a school setting, documenting on an IEP, or in acute care, assessing if a patient can return home or requires a skilled nursing facility. Perhaps you're in a wound clinic, noting the type of dressing needed, or in a sports clinic, determining if a patient is fit to return to play or wear protective gear. Maybe you're in a wellness center, where patients are self-paying, or in home health, assessing if they're homebound. You could be in a skilled nursing facility, a long-term acute care setting, an inpatient rehab facility, or even working in early intervention, striving to use family-friendly language. Regardless of the setting, as physical therapists, our primary focus is maximizing the patient's function. In this final section, I want to emphasize the importance of considering the patient or client's perspective, needs, and goals.

Unique Patient Populations

The unique patient populations, particularly the distinct demographics of rehabilitation versus long-term care, pose specific challenges. According to Ecler et al., "Geriatric patients are complex. The typical older adult is more likely to suffer from severe end-stage diseases, adverse effects of polypharmacy, and lack of social support, resulting in poorer overall outcomes." Long-term care often transitions into end-of-life care, an inevitable reality for all of us. Dealing with these situations can be one of the most challenging aspects of documentation. Maintenance therapy cases can be particularly difficult when patients do not show improvement. Oftentimes, patients may refuse to participate due to a perceived lack of ability to improve.

Jimmo vs. Sebelius

I wanted to take a moment to discuss Jimmo versus Sebelius. For those who may not be familiar, this landmark case occurred in 2013. In this case, a federal judge ruled to ensure that therapy services are available for beneficiaries whose condition is not improving. The coverage for skilled care is necessary to restore, maintain, prevent, or slow deterioration so long as the beneficiary requires skilled care for services to be safe and effective. Maintenance therapy is now recognized as a right, and I'd like to delve into goal-setting for maintenance therapy a bit further today.

To Improve or Not, That is the Question

CMS defines restorative therapy and maintenance therapy differently. Maintenance therapy involves the therapist's skills to maintain, prevent, or slow further deterioration of the patient's functional status. These services cannot be safely and effectively carried out by the patient alone or without the assistance of a therapist, including caregivers. Let's pause for a moment on this. When we discussed documenting skill earlier, we emphasized documenting why you were needed. Similarly, when it comes to maintenance therapy, it's crucial to document why you're needed. By documenting the necessity of your involvement, you can effectively justify the need for maintenance therapy.

Decline Expected (A Palliative Mindset)

Let's discuss those whose decline is expected. According to the World Health Organization, palliative care is an approach that "improves the quality of life of patients and their families who are facing challenges associated with life-threatening illness, whether physical, psychological, social, or spiritual."  When it comes to geriatric pain, "There is a need to consider and understand the complexity and multi-dimensionality of older people's pain-related problems at the end of life. To address the complexity of needs among older people at the end of life, patient documentation must be structured and tailored to capture their needs comprehensively. The documentation must be based on the people's needs and desires regarding the dying process" (Sjoberg et al., 2021). This statement can be generalized to encompass the hospice palliative care process and any challenging patient scenario where participation is limited or goals are not explicitly stated.

Palliative Documentation

To document a patient who may not show improvement or to establish a decline goal, consider framing it in terms of what the patient would not be able to do if you were not involved. This approach applies to palliative documentation as well. If a patient is expected to experience a decline within a defined time period, the goal should aim to extend that timeframe or to maintain a certain level of function.

For instance, let's take a patient currently ambulating without an assisted device but with an expected decline. Your goal could articulate that the patient will transition to using a walker rather than a wheelchair within six weeks to maintain functional mobility within their home. Describe the patient's condition without your intervention, and then outline how you can assist them. State what the patient would be like without your help. Essentially, it's akin to restorative therapy but tailored to address potential decline.

For example, consider a post-op patient following a total knee replacement. If the patient would typically achieve 50 degrees of range post-op and might reach 75 degrees independently, but with therapy, they could attain 90 degrees within a week, set a goal for them to reach 90 degrees.

In the case of a patient with an anticipated decline, specify what their decline would entail and then outline the level of function you aim to maintain with your involvement. For instance, if a patient would become non-ambulatory within a certain period, establish a goal to sustain their ambulatory status. Similarly, if a patient would lose the ability to tolerate sitting within a timeframe, set a goal to maintain their ability to sit comfortably.

Patient Directed Goals

We all have experienced a patient that "doesn’t have any goals.” Documenting patients who lack predefined goals poses a significant challenge as it complicates the process of linking interventions to functional outcomes. This absence of clear goals makes incorporating the "in order to" component difficult. In a 2019 journal article by Kittelson et al., the team refers to the Sicilian statement on evidence-based practice, emphasizing that "healthcare decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing the care, within the context of available resources." Engaging with a patient's wishes becomes even more crucial, and arguably more so towards the end of life.

Goal Setting for Palliative Care

In the recent study by Okita et al. (2023), goal setting for palliative care was examined alongside the characteristics of goal setting in adult rehabilitation, as highlighted in a scoping review. Clinical practice guidelines often emphasize the integration of goal setting into the rehabilitation process. This integration is believed to enhance a client's motivation and engagement in rehabilitation while also improving communication and collaboration between healthcare practitioners and clients. Ultimately, this leads to accelerated recovery and better health outcomes.

The study investigated various goal-setting tools, some considered impairments and abilities while engaging in goal-directed behavior. It was a comprehensive study that offered valuable insights into the importance and effectiveness of goal setting in rehabilitation and palliative care. If you're interested in exploring goal-setting tools further, particularly in the context of rehabilitation and palliative care, the resources referenced in the study by Okita are highly recommended. These tools were found to be excellent and offer valuable insights into effective goal-setting practices.

When it comes to setting goals, it's essential to focus on outcomes that truly matter to the individual. Identifying what is personally meaningful to the patient is a crucial aspect of the goal-setting process. This may require delving deep into understanding the patient's values, preferences, and aspirations. However, this investment of time is essential for crafting goals that resonate with the patient and align with their unique needs and desires.

Revisiting Cases

I want to revisit the examples from SMART or Not So Smart? as those examples were patients of mine. The patient aiming to ambulate 50 feet with handheld assistance on an even surface without a loss of balance within a month to walk his daughter down the aisle was indeed under my care. However, I want to delve deeper into the documentation process and how it facilitated his progress. While writing a SMART goal is crucial, engaging the patient and advocating on their behalf is equally vital. Hence, the title of this course is "Documentation: An Opportunity to Advocate for Your Patient."

My documentation played a pivotal role in advocating for this patient. Initially, I struggled to secure approval for visits as it was deemed that he lacked the potential for improvement. Yet, upon assessing him, I found he was already ambulating over 50 feet and displaying some independence. Surprisingly, he expressed no desire for therapy, even stating, "I probably won't be alive when my daughter is married." Given his significant COPD and limited life expectancy, this sentiment was not unfounded.

Despite resistance from the hospice team and uncertainties from the insurance company, I persisted in advocating for him. I urged the company I worked for to allow me a few visits, emphasizing the potential benefits of therapy. Each time I submitted my documentation, it meticulously depicted his progress, particularly focusing on energy conservation strategies. I detailed our plans, including his preference to use a cane rather than a walker and how we tailored his morning routine. His determination was evident when, despite multiple breaks, he managed to walk his daughter down the aisle and receive a rose from her.

Documenting progress isn't always about justifying claims to insurance; sometimes, it's about advocating within our organizations. In this case, I had to advocate for a patient who initially declined therapy. Ultimately, he was pleased with the outcome. Though he passed away two weeks after his daughter's wedding, the memory of him walking her down the aisle remains poignant. I often refer to hospice examples because they resonate deeply with me, despite the initial reluctance I face from patients in such situations.

Let's go back to the case about SMART sitting. The goal was: Patient will tolerate upright sitting balance as evidenced by maintaining oxygen saturation at or above 95%, no complaints of increased shortness of breath, or increased respiratory rate by more than four breaths a minute for 20 minutes within 30 days to decrease risk for respiratory infection and to enjoy bird watching.

This particular patient, a cheerful lady, resided in a skilled nursing facility. When I initially assessed her, she expressed contentment and claimed she didn't require any therapy. However, I observed that she remained confined to her bed, showing no inclination to mobilize. Despite my attempts to encourage her during the first few visits, she adamantly refused treatment.

On my third visit, as I prepared to discharge her due to her noncompliance, she said, "I think I hear birds outside." Recognizing an opportunity, I suggested, "If you're willing to sit in the chair, I can help you over to the window to see the birds." Although she initially appeared indifferent to my warnings about the risk of respiratory infections from prolonged bed rest, she eventually agreed. I managed to facilitate her movement to the window, where she could watch the birds.

While seated, her respiratory rate noticeably increased, underscoring the effects of prolonged immobility. Despite her reluctance to engage in therapy, I succeeded in negotiating an increase in her therapy sessions at the skilled nursing facility. Over time, I managed to transition her to sitting in a chair with some support, albeit with minimal participation in therapy sessions.

This case highlights the importance of patient engagement and understanding their priorities. Despite her initial resistance, I was able to establish a connection with her by identifying what mattered most to her. In my documentation, I relied on my goals to guide my interactions with her, ensuring that each session was purposeful and tailored to her needs.

Summary

Advocacy is a multifaceted aspect of our profession. Sometimes, it involves advocating for our patients with our employers or insurance companies. Other times, it means motivating the patients themselves to engage in therapy. Regardless, it's universally true that everyone has something that matters to them, and it's our responsibility as therapists to uncover that.

Discovering what matters to our patients may not happen on the first visit; it often requires digging deep. Goals serve as the gateway to achieving outcomes. As therapists, we strive for positive functional improvements and maximizing our patients' potential. Ethically, we must document our interventions accurately and comprehensively, whether through electronic systems, traditional SOAP notes, or other means.

According to Medicare guidelines, medical necessity is determined by our documentation, highlighting the necessity for skilled intervention to ensure safe and effective service delivery. This holds true regardless of the patient's ability to achieve the goals or financial status.

In reviewing SMART goals, remember the importance of being specific, measurable, achievable, and challenging, with a clear understanding that these goals require our expertise. Time-bound objectives provide structure, and in maintenance therapy, skilled intervention remains crucial. In palliative care, therapy aims to enhance the quality of life for patients.

Questions and Answers

Can you review SMART goals being relevant?

The World Health Organization utilizes the International Classification of Functioning, Disability, and Health (ICF) system, which connects health conditions to body functions and structures, activities and participation, and environmental and personal factors. It's essential to tailor this framework to the individual patient as much as possible.

Engaging with the patient to understand their priorities and values can reveal what matters most to them. Some effective questions to elicit this information include: What future activities are you concerned about being unable to participate in? What activities bring you joy? What activities did you enjoy before experiencing limitations? Exploring the patient's previous level of function can also be illuminating. Activities and participation are key areas to consider when developing relevant components for SMART goals.

Standardized tests and measures may highlight areas of functional impairment, but they may not always capture the full depth of the patient's experience. Goals related to activities of daily living (ADLs) such as bathing, walking, or transferring in and out of bed, can be equally important. Keeping a journal of the patient's daily activities can provide valuable insights into their preferences and routines.

Can you elaborate a little more on maintenance therapy, such as the number of times per week? Can you do one time per week with restorative aids, or does the therapist provide all visits?

There is no set frequency or duration for restorative therapy, as it depends on the individual's needs and the necessity for skilled intervention. The requirement for skilled intervention determines the frequency of restorative therapy visits. Similarly, if asked to elaborate on restorative therapy, such as the number of weekly visits, the response would be nearly identical to that of skilled therapy.

For instance, if someone requires maintenance therapy and receives restorative aids, such as a home exercise program with periodic modifications, the frequency of visits may be less frequent. This lower frequency is acceptable if it meets the patient's needs.

Conversely, maintenance therapy visits can occur frequently if skilled intervention is essential for the patient's safety. In such cases, if the treatment requires the expertise of a physical therapist and cannot be safely performed by someone else, the frequency of maintenance therapy visits may be increased accordingly.

In clinical practice, what is your rationale for determining whether a patient is more appropriate for restorative versus maintenance therapy?

The determination between restorative and maintenance therapy hinges on the patient's likelihood of improvement. This assessment involves making an educated guess regarding the patient's potential for improvement. Just like setting goals for improvement, there is a possibility of being incorrect in predicting the patient's progress. If the patient does not show the expected improvement, adjustments to the treatment plan are necessary.

Most insurance companies do not differentiate between restorative and maintenance therapy in their billing codes. Therefore, from a billing perspective, it usually does not make a significant difference whether the therapy is classified as restorative or maintenance. Therapists may initially aim for restorative therapy, but if the patient does not make expected gains or if it becomes evident that improvement is unlikely, they may switch to maintenance therapy. Ultimately, the decision is based on the patient's progress and needs, with adjustments made as necessary.

Productivity demands encroach on timely documentation. How would you address this or strategies to be more successful? For example, 15 to 18 patients over an eight-hour day, averaging five to eight minutes a note, there will be an impact somewhere on quality. Quality of visit versus interaction quality of documentation.

On days when the caseload is high, integrating documentation into patient visits can be a practical approach to manage time efficiently. If a treatment session does not involve hands-on therapy, such as when a patient is undergoing a modality, using that time for documentation can be beneficial. However, this may not be feasible if the treatment session requires constant hands-on therapy.

Finding a balance between patient care and documentation is crucial. It's essential to prioritize quality documentation while acknowledging the constraints of an eight-hour workday. Collaborating with supervisors to enhance efficiency in documentation is key. Shadowing colleagues who excel in documentation within the electronic health system can provide valuable insights into optimizing workflow. Observing those who have mastered the system can offer effective strategies for navigating electronic health records. Requesting opportunities to shadow proficient colleagues is a recommended approach to improve efficiency in documentation.

I was recently warned against putting standardized tests into goals such as patient will improve balance, as evidenced by TUG score. But I think this is still okay to have tied to a specific function, such as the patient's balance will improve to allow her to walk to the bathroom as evidenced by...

I've been cautioned against that approach because it might be about improving the test score if it's not linked to function. By stating, "allowing her to walk to the bathroom," you tied the goal directly to a functional activity. Conversely, if you state, "patient will improve TUG score," it lacks this functional connection. However, if you phrase it as "patient will improve, allowing her to walk to the bathroom as evidenced by an improved TUG score," it aligns the goal with function and demonstrates measurability.

If someone insists that an improved test score cannot serve as evidence for the goal, or if they prefer not to use it, consider extracting a component of the test. For instance, you could write, "Patient will be able to stand and walk." It's about integrating the test components into the goal statement rather than the test name. So, for example, with the Tinetti or Berg tests, focus on specific components rather than the test names.

Point of service documentation is almost impossible in any skilled nursing facility, as we share tablets and therefore can't take them with us into the patient room.

It's crucial to acknowledge the challenges faced in skilled nursing facilities, where real-time documentation is key. The timing of documentation is vital, with immediacy being the priority. Waiting until the end of the day is less ideal than documenting right after patient treatment. The closer to the patient interaction, the better. For instance, if you're treating multiple patients in the gym, taking a break to document immediately afterward is preferable to delaying until the day's end. In your scenario, consider aiming for documentation during lunchtime, mid-morning, mid-afternoon, and day's end to ensure documentation occurs as close to patient interaction as possible.

How would you recommend a progress note be written for a SMART goal?

Let's delve into the components of a SMART goal and explore how they inform the structure of a progress note. The specificity, measurability, and achievability of a SMART goal guide the content of the progress note, offering clear direction on what to include. For instance, consider a goal related to ambulation. In our progress note, we would detail the number of feet ambulated, any instances of balance loss, the type of surface traversed, and the level of assistance provided. Similarly, for a goal concerning sitting tolerance, we would record the patient's oxygen saturation percentage, any observed increase in respiratory rate, and the duration of the sitting activity.

By incorporating these measurable elements into our goals, we gain clarity on the parameters to be documented in our progress notes. For example, the goal's measurability prompts us to monitor the patient's respiratory rate before and during the sitting activity and track the duration of the activity itself.

I have an MS patient who does not require skill for range of motion, so RNA was trained. The patient cannot do any mobility functionally but can sit for 15 minutes with min to mod assist. Since the staff uses Hoyer, I assume I couldn't keep her on maintenance just to sit her up. Is this accurate thinking?

Since she can't perform mobility tasks independently but can sit for 15 minutes with assistance, we need to assess the level of assistance provided. If the assistance required is skilled, such as mid to moderate assistance, and cannot be provided by RNAs, then your expertise would be necessary to maintain her care. However, if the assistance needed is non-skilled, your involvement may not be warranted.

Documenting these details comprehensively and linking them to functional outcomes is crucial. Consider the broader benefits of sitting even if her functional abilities are limited. How does it impact her respiratory or digestive systems? By highlighting these aspects, you can justify the need for skilled intervention.

Remember, it's likely not a skilled intervention if five non-therapists can perform the task without you. Ensure that your involvement is indeed necessary based on the specific requirements of the assistance provided.

Would a one to two-year post-CVA in a skilled nursing facility be considered for maintenance therapy due to a decline in function, contracture, et cetera?

Absolutely. Even before a decline occurs, the goal is potentially transitioning patients to a maintenance program to prevent deterioration. This aligns with the essence of Jimmo versus Sebelius, where improvement isn't the sole criterion, but rather, the prevention of decline is emphasized. However, predicting potential declines without ongoing care is often challenging. It's usually after the fact that evidence of decline becomes apparent in the absence of therapy.

This retrospective insight allows us to advocate for maintenance therapy by demonstrating how patients' function deteriorated without intervention. Contractures and other functional declines serve as tangible evidence to support the necessity of ongoing care. So, indeed, this scenario underscores the importance and relevance of maintenance therapy.

References

Cantu, R. (2019). Physical therapists’ ethical dilemmas in treatment, coding, and billing for rehabilitation services in skilled nursing facilities: A mixed-method pilot study. Journal of the American Medical Directors Association, 20(11). https:// doi.org /10.1016/j.jamda.2019.06.013

Jaqua, E. E., Chi, R., Labib, W., Uribe, M., Najarro, J., & Hanna, M. (2020). Optimize your documentation to improve Medicare reimbursement. Cleveland Clinic Journal of Medicine, 87(7), 427 – 434. https://doi.org/10.3949/ccjm.87a.19116

Kittelson, A. J., Hoogeboom , T. J., Schenkman , M., Stevens-Lapsley, J. E., & van Meeteren, N. L. (2019). Person-centered care and physical therapy: A “people-like-me” approach. Physical Therapy, 100(1). https:// doi.org /10.1093/ ptj /pzz139

Medicare. (2021, March 17). What does “medically necessary” mean? Medicare & Medicare Advantage Info, Help and Enrollment. https://www.medicare.org/articles/what-does-medically-necessary-mean/ 

Okita, Y., Kawaguchi, Y., Inoue, Y., Ohno, K., Sawada, T., Levack, W., & Tomori, K. (2023). Characteristics of goal-setting tools in adult rehabilitation: A scoping review. Clinical Rehabilitation, 38(2). https:// doi.org /10.1177/02692155231197383

Sjöberg, M., Edberg, A. K., Rasmussen, B. H., & Beck, I. (2021). Documentation of older people’s end-of-life care in the context of specialized palliative care: A retrospective review of patient records. BMC Palliative Care, 20(1). https://doi.org/10.1186/s12904-021-00771-w

Stikeleather, S. J., & Simmons, T. M. (2021). Maintenance physical therapy: Consideration for a continuous practice paradigm for physical therapists. Topics in Geriatric Rehabilitation, 37(3), 152-162.