Therapy Screening

Question

Answer

The purpose of a rehab screen is for the therapist to attempt to identify clients' needs and possible rehab potential.  A screen may not result in a therapy evaluation.  It does not require a physician order.  The screen is used to support and provide additional documentation on the evaluation findings to support medical necessity.  No recommendations can be made other than evaluation or no evaluation. It is a hands-off review to ID those needing therapy intervention. 

Screening should focus on screening clients with a change in function and when appropriate these clients should be referred to therapy.  

For best practices, 

• Screen will determine if an evaluation is needed
• Evaluation will determine if further rehab potential and goals can be established 
• Use clinical reasoning skills to determine if the client warrants a skilled plan of care

Tips for success:

• Effective communication between nursing and therapy
• Regular meetings with the nursing staff
• Utilize a nursing referral form
• Supportive documentation is present
• Provide in-services to the multidisciplinary team
• Obtain info from various sources

A screening chart review should include: 

• Nurses notes-daily nursing documentation may illustrate a pattern which warrants a screen
• MD notes
• CNA flow sheets
• Restorative nursing notes
• Previous therapy notes and discharge summary

Example of clients to be screened are those who have:

• Had a fall
• Abnormal posture
• Poor head, neck, or trunk control
• Contractures
• Problems with edema
• Decreased safety awareness
• Decreased transfer ability
• Decreased ability to re-position self
• Poor supported sitting balance
• Poor skin integrity
• Pressure injuries
• Difficulty eating or swallowing
• Decreased participation in ADL
• Complaints of pain
• Decreased ability to self-propel wheelchair
• Difficulty breathing
• Decreased socialization due to poor position
• Difficulty maneuvering wheelchair in environment
• Difficulty using motorized wheelchair or scooter