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Third Edition

Documentation Basics for the Physical Therapist Assistant

Core Texts for PTA Education

Third Edition

Documentation Basics for the Physical Therapist Assistant

Core Texts for PTA Education

MIA L. ERICKSON, PT, EDD, CHT, ATC Midwestern University

Physical Therapy Department Glendale, AZ

REBECCA MCKNIGHT, PT, MS Educational Consultant Reach Consulting, LLC

Forsyth, MO

www.Healio.com/books

Copyright © 2018 by SLACK Incorporated

Dr. Mia L. Erickson and Rebecca McKnight have no financial or proprietary interest in the materials presented herein.

All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher, except for brief quota- tions embodied in critical articles and reviews.

The procedures and practices described in this publication should be implemented in a manner consistent with the professional standards set for the circumstances that apply in each specific situation. Every effort has been made to confirm the accuracy of the information presented and to correctly relate generally accepted practices. The authors, editors, and publisher cannot accept respon- sibility for errors or exclusions or for the outcome of the material presented herein. There is no expressed or implied warranty of this book or information imparted by it. Care has been taken to ensure that drug selection and dosages are in accordance with currently accepted/recommended practice. Off-label uses of drugs may be discussed. Due to continuing research, changes in government policy and regulations, and various effects of drug reactions and interactions, it is recommended that the reader carefully review all materials and literature provided for each drug, especially those that are new or not frequently used. Some drugs or devices in this publication have clearance for use in a restricted research setting by the Food and Drug and Administration or FDA. Each professional should determine the FDA status of any drug or device prior to use in their practice.

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Instructors: Documentation Basics for the Physical Therapist Assistant, Third Edition Instructor’s Manual is also available from SLACK Incorporated. Don’t miss this important companion to Documentation Basics for the Physical Therapist Assistant, Third Edition. To obtain the Instructor’s Manual, please visit http://www.efacultylounge.com

CONTENTS About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Chapter 1 Disablement and Physical Therapy Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 2 The Physical Therapy Episode of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Rebecca McKnight, PT, MS

Chapter 3 Reasons for Documenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 4 Documentation Formats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 5 Electronic Medical Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 6 Basic Guidelines for Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Rebecca McKnight, PT, MS and Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 7 Interpreting the Physical Therapist Initial Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Rebecca McKnight, PT, MS

Chapter 8 Writing the Subjective Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Rebecca McKnight, PT, MS

Chapter 9 Writing the Objective Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Rebecca McKnight, PT, MS

Chapter 10 Writing the Assessment and Plan Sections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Rebecca McKnight, PT, MS

Chapter 11 Payment Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 12 Legal and Ethical Considerations for Physical Therapy Documentation . . . . . . . . . . . . . . . . 119 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 13 Documentation Across the Curriculum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Mia L. Erickson, PT, EdD, CHT, ATC

Traumatic Brain Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Tracy Rice, PT, MPH, NCS

Spinal Cord Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Tracy Rice, PT, MPH, NCS

Appendix: Abbreviations and Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155

Instructors: Documentation Basics for the Physical Therapist Assistant, Third Edition Instructor’s Manual is also available from SLACK Incorporated. Don’t miss this important companion to Documentation Basics for the Physical Therapist Assistant, Third Edition. To obtain the Instructor’s Manual, please visit http://www.efacultylounge.com

ABOUT THE AUTHORS Mia L. Erickson, PT, EdD, CHT, ATC, is a faculty member in the Physical Therapy Department at Midwestern

University in Glendale, AZ. Mia earned a bachelor’s degree from West Virginia University in secondary education in 1994 and a master of science degree in physical therapy from the University of Indianapolis in 1996. Mia earned a doctoral degree in education from West Virginia University with an emphasis on curriculum and instruction in 2002. Her clinical practice is in the area of hand and upper-extremity rehabilitation.

Rebecca McKnight, PT, MS, received her bachelor of science degree in physical therapy from St. Louis University in 1992 and her postprofessional master of science degree from Rocky Mountain University of Health Professions in 1999. She taught at Ozarks Technical Community College for 14 years, serving as Program Director for 9 of those years. Rebecca is an active member of the American Physical Therapy Association and is a former chair of the Physical Therapist Assistant Educators Special Interest Group of the education section. Rebecca has spoken at many national meetings on physical therapist assistant curriculum design and programmatic assessment. She is the 2009 recipient of the F.A. Davis Award for Outstanding Physical Therapist Assistant Educator. Rebecca has been providing educational consultation in the areas of curriculum design, development, and assessment for physical therapist assistant programs nationwide since 2007.

PREFACE We would like to thank you for choosing the Third Edition of Documentation Basics for the Physical Therapist Assistant.

We think that you will find some substantial changes that make this edition more modern, reflecting contemporary prin- ciples in documentation. Two of the biggest changes are incorporation of the International Classification of Functioning, Disability and Health (ICF) disablement model (vs other models that have been discussed in previous editions) and further integration of the electronic medical record. The ICF serves as the framework for several important aspects of this text. Throughout, we encourage readers to really think about disablement and disablement concepts when writing notes. This includes documenting impairments in body structure and function in addition to activity limitations and participation restriction. We also encourage the reader to frequently note improvements in impairments, activity limitations, and par- ticipation restrictions brought on by the intervention provided in objective terms so that others reading the documentation can see the improvement.

This edition has been updated in its discussion of the electronic medical record. In addition to describing the differ- ences in documentation methods using a computer vs a paper chart, this edition features a stand-alone chapter on the electronic medical record. It walks the reader through differences in the electronic health and medical records and dis- cusses the rationale for change to electronic record keeping. The book also incorporates some evidence tied to benefits and challenges of computerized documentation. We were fortunate enough to have WebPT® (Phoenix, AZ) allow us to integrate screen shots from its computerized documentation system. This enables the reader to see what a screen would look like in various parts of the medical record.

We continue to incorporate concepts related to documenting the rationale for treatment and note how the unique skills of the physical therapist assistant were used in patient management. Examples, or “how-tos,” are also provided. We feel like these changes are unique to our text and can help readers to understand these important aspects of documentation in today’s payer system.

While we continue our instruction in writing a note using the SOAP (subjective, objective, assessment, and plan) struc- ture, we recognize and point out its flaws. We still believe that understanding parts of notes using the SOAP acronym can help students to learn the fundamentals and then, when they get to the clinical site, they can integrate their knowledge into the software or charting system used at that site.

Again, we are happy to provide you with this updated version of our book, and we hope that you enjoy it, whether you are using it as a physical therapist assistant student, a physical therapist assistant educator, or a clinician.

Mia L. Erickson, PT, EdD, CHT, ATC

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 1-7)

© 2018 SLACK Incorporated 1

Disablement and Physical Therapy Documentation

Chapter 1

After reading this chapter, the reader will be able to do the following: 1. Define disablement. 2. Define terminology used in the International

Classification of Functioning, Disability and Health (ICF).

3. Differentiate between impairment, activity limitation, and participation restriction.

4. Define documentation. 5. Describe the need for common language in physical

therapy documentation. 6. Describe how disablement concepts can be integrated

into physical therapy documentation. A traditional approach to defining a person’s health

comes from the biomedical model in which health means free or absent from disease.1 The biomedical model implies that accurate diagnosis and identification of the patient’s biological defects can directly lead to selection of interven- tions that will maximize health outcomes.1 In this model, however, there is little emphasis on how the disease affects

the person’s ability to function or participate within society on a daily basis. Over the last few decades, many reha- bilitation professionals have shifted their focus away from managing the disease or pathology and have moved toward managing the consequences of the disease or condition. It has become more common to focus on these consequences as they pertain to the individual’s ability to carry out tasks and function within society. Assessing functional perfor- mance and describing functional status are now primary components of the physical therapist’s examination of the patient. Verbrugge and Jette2 described the consequences that chronic and acute conditions have on specific body system function and on a person’s ability to act in neces- sary, usual, expected, and personally desired ways in his or her society as disablement. These authors explained that disablement is a “process,” indicating that it is dynamic, or a trajectory of functional consequences over time. A more contemporary approach to physical therapy patient man- agement is to incorporate disablement and disablement concepts.

Individuals and groups throughout the world have developed disablement frameworks. Disablement frame- works are useful for providing a common language for health care providers, and they can serve as a basic archi-

CHAPTER OBJECTIVES

KEY TERMS Activity | Activity limitation | American Physical Therapy Association | Biomedical model | Body functions | Body structures | Contextual factor | Disablement | Documentation | Environmental factor | International Classification of Functioning, Disability and Health | International Classification of Diseases, Tenth Revision | Participation | Participation restriction | Personal factor | Physical therapist

KEY ABBREVIATIONS APTA | ICD-10 | ICF | PT | WHO

Chapter 12

tecture for research, policy, and clinical care.2 In addi- tion to providing infrastructure, disablement frameworks define health in terms that go beyond the patient’s medical diagnosis or disease, acknowledging the importance of societal, psychological, and physical functioning. Rather than placing the measure of health on the disease process itself, these models have helped providers to shift toward understanding an individual’s ability to carry out neces- sary life tasks and to function within society. Disablement frameworks have attempted to delineate a pathway from pathology to functional outcome while recognizing the social, psychological, and environmental factors that can facilitate or interfere with the pathway.2 The purpose of this chapter is to introduce you to the disablement frame- work used in physical therapy practice and to introduce the purpose of using disablement and disablement concepts in clinical documentation.

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH

The ICF, originally known as the International Classification of Impairments, Disabilities, and Handicaps, was endorsed by the 54th World Health Assembly and released in 2001. The ICF provides a uniform, standard language for describing an individual’s health and health- related state that moves beyond his or her diagnosis.3 In 2008, the American Physical Therapy Association (APTA) House of Delegates voted to endorse the ICF and, as a result, APTA publications, documents, and communications have been updated to incorporate the ICF language (Example 1-1).4 Therefore, the ICF serves to provide a common lan- guage for physical therapists to communicate.

Example 1-1 The following definitions have been endorsed by the World Health Organization as part of the ICF3:

• Functioning is an umbrella term that includes all body functions, activities, and participation. • Disability serves as an umbrella term for dysfunction at any one or more of the following levels: impairment, activity limitation, and participation restriction.

• Body functions are physiological functions of the body (including psychological function). • Body structures are anatomical bodily structures, such as organs and limbs. • Impairments are problems with body functions (physiological, psychological) or structures, such as a deviation or loss.

• Activity is the execution of a task or activity by an individual. • Activity limitations are difficulties that might be encountered by an individual who is attempting to complete a task or carry out an activity.

• Participation is involvement in a life situation, such as work or school. • Participation restrictions are problems an individual might face while involved in life situations.

• Contextual factors are the complete factors that make up a person’s life and living, including his or her background.

• Environmental factors are the physical, social, and attitudinal environmental in which people live and carry out their lives. These include things immediate to the individual, such as his or her home or workplace, and the larger social context, such as government agencies designed to assist people with disabilities.

• Personal factors are factors specific to the individual and his or her background. These include things such as age, gender, social habits, health habits, upbringing, and coping strategies.

Disablement and Physical Therapy Documentation 3

In the ICF, the individual’s health or health-related state is described in terms of function and disability. What the individual can do is known as functioning, or the positive aspects of health. What the individual cannot do is known as disability, or the negative aspects of health (Figure 1-1).3 Function and disability comprise Part 1 of the ICF. Part 1 is further divided into the following 2 components: (1) body functions (physiological function) and body struc- tures (anatomical structures) and (2) activities and partici- pation (Figure 1-2).3 In categorizing an individual’s health according to the ICF, a health care provider would describe body structures and functions that are intact and those that are not intact. Any deviation(s) from normal body structure and/or function are known as impairments. For the activities and participation component, the exam- iner identifies functional tasks that the individual can do (known as activities) and those that he or she cannot do (known as activity limitations). The examiner also identi-

fies life roles that the individual can carry out (known as participation) and those that he or she cannot carry out (known as participation restrictions; see Figure 1-1).3

The ICF also accounts for contextual factors that might facilitate or impede the patient’s function. These appear in Part 2, which also includes environmental and personal factors that affect the individual’s functioning and dis- ability. Environmental factors are external factors that are either within the individual’s immediate environment or part of a larger social structure and that affect the individual’s ability to participate in society. These might be facilitators, which enhance participation, or barriers, which deter participation. Environmental factors include things such as physical structures (eg, ramps, stairs, curbs). Personal factors are those that are unique to the individual, such as attitude, mood, or family support (see Figure 1-2).3

Figure 1-1. Overview of the International Classification of Functioning, Disability and Health.3 The string of boxes on the left repre- sents the positive aspects of the health state or condition. The string of boxes on the right rep- resents deviations from normal, or the negative aspects of health.

Body-level

Individual- level

Societal- level

ICF

Health and Health- Related States

Function: What the individual

CAN do (Positive Aspects of

Health)

Disability: What the individual

CANNOT do (Negative Aspects

of Health)

Body tissues and/ or structures that

are intact and functioning

(Normal)

Body tissues and/ or structures that are not intact or

functioning (Impairments)

Tasks an individual CAN carry out

(Activities)

Tasks an individual CANNOT carry out

(Activity Limitations)

Roles in which an individual CAN

participate (Participation)

Roles in which an individual CANNOT

participate (Participation Restrictions)

Chapter 14

The ICF is part of a “family” of classifications created by the World Health Organization (WHO) known as the WHO Family of International Classifications.5 This family also includes the International Classification of Diseases, Tenth Revision (ICD-10), a classification system for medical diagnoses and diseases. The ICD-10 is the diagnostic clas- sification standard for all clinical and research purposes. It defines the universe of disease, disorders, injuries, and other related health conditions, listed in a comprehensive format.6 The ICF and ICD-10 are meant to complement each other in that the ICD-10 provides a catalog of medical diagnoses, diseases, disorders, and health conditions and the ICF provides corresponding information on function and disability. Used together, they provide a broader picture of an individual’s health.7

PHYSICAL THERAPY AND DISABLEMENT The ICF provides clinicians with standardized termi-

nology and a framework to aid in exploring the impact of disease or injury on an individual’s daily life. More spe- cifically, physical therapy providers can use the ICF to help understand the consequences of the disease or condition on the body systems and the impact on the individual’s activ- ity level and participation within society. Consideration

of disablement when working with patients helps physical therapy providers to realize more complex functional and social issues that patients face.

Individuals in need of physical therapy services often have a disease or injury with resulting impairments in body structure(s) and/or function(s), activity limitations, and participation restrictions that are identified during the physical therapist’s examination. Impairments can be limitations in range of motion, strength, endurance, or balance, to name a few. But to see how the patient’s abil- ity to participate in society has been compromised, the examination must go beyond the impairment level. It is our responsibility to understand how impairments affect the patient’s day-to-day activities and participation in a variety of settings and situations; therefore, the physical therapist’s examination of patient function includes assessment of the following: (1) activities such as bed mobility, transfers, hygiene, self-care, and home management (eg, yardwork, household cleaning); and (2) participation such as the abil- ity to work, go to school, play, and participate in commu- nity activities (eg, going to the grocery store or bank). By understanding an individual’s impairments and his or her activity limitations and participation restrictions, we can better understand the degree of disability associated with the pathology for the individual patient.

Figure 1-2. The International Classification of Functioning, Disability and Health3 from the WHO. (Reprinted with permis- sion from the WHO.)

Disablement and Physical Therapy Documentation 5

DOCUMENTATION AND DISABLEMENT Documentation, otherwise known as medical record

keeping, has been defined as “any entry into the individu- al’s health record, such as a(n) consultation reports, initial examination reports, progress notes, flow sheets, checklists, re-examination reports, or summations of care, that identi- fies the care or services and the individual’s response to intervention.”8 Complete documentation also includes the physician prescription(s) and certification(s), communica- tion with other care providers, copies of exercise programs or patient instructions, and any other disciplines’ notes or comments that support the interventions.9

As you will read in subsequent chapters, documenta- tion will serve many purposes, but, regardless of the pur- pose, your documentation should reflect disablement. One reason for integrating disablement concepts in physical therapy documentation is to achieve consistency in termi- nology because our notes are the sole record of the episode of care provided to each patient or client. Another reason is to show the reader how the patient’s pathology and impair- ments influence his or her activities and participation in daily life. Disablement concepts serve as a foundation for this text. Throughout the chapters, you will be reminded of the following 3 important disablement concepts that should be integrated into your clinical documentation: 1. Documentation should reflect not only measures of

impairment, but also measures of activity limitations and participation restrictions.

2. Documentation should describe how the patient’s impairments relate or contribute to his or her activity limitations and participation restrictions.

3. Documentation should explain how physical therapy interventions are bringing about changes in impair- ments, activity limitations, and participation restric- tions that relate to the patient’s therapy goals.

REFERENCES 1. MacDermid JC, Law M, Michlovitz SL. Outcome mea-

surement in evidence-based rehabilitation. In: Law M, MacDermid JC, eds. Evidence-Based Rehabilitation: A Guide to Practice. 3rd ed. Thorofare, NJ: SLACK Incorporated; 2014:65-104.

2. Verbrugge LM, Jette AM. The disablement process. Soc Sci Med. 1994;38(1):1-14.

3. World Health Organization. International Classification of Functioning, Disability and Health: ICF. Geneva: World Health Organization; 2001.

4. American Physical Therapy Association. International Classification of Functioning, Disability, and Health. APTA Website. http://www.apta.org/ICF/. Updated August 23, 2013. Accessed October 24, 2016.

5. Madden R, Sykes C, Ustun TB. World Health Organization Family of International Classifications: definition, scope, and purpose. World Health Organization Website. http://www. who.int/classifications/en/FamilyDocument2007.pdf?ua=1. Updated February 2, 2012. Accessed October 24, 2016.

6. World Health Organization. Classifications: International Classification of Disease. WHO Website. http://www.who. int/classifications/icd/en/. Updated June 29, 2016. Accessed October 24, 2016.

7. Escorpizo R, Bemis-Dougherty A. Introduction to spe- cial issue: a review of the International Classification of Functioning, Disability and Health and physical therapy over the years. Physiother Res Int. 2015;20(4):200-209.

8. American Physical Therapy Association. Guide to Physical Therapist Practice 3.0. APTA Website. http://guidetoptprac- tice.apta.org/content/1/SEC2.body. Updated August 1, 2014. Accessed October 24, 2016.

9. Redgate N, Foto M. Pay by the rules: avoid Medicare audits and reduce payment denials with a sound strategy and prop- er documentation. Physical Therapy Products. 2003;October/ November:28-30.

Chapter 16

REVIEW QUESTIONS 1. How is a person’s health determined today as opposed to 5 decades ago?

2. In your own words, describe disablement.

3. According to the ICF, what is the difference between an impairment, an activity limitation, and a participation restriction?

4. Why is there a need for disablement models today? Why are they important to you?

5. What is physical therapy documentation? What does it include?

6. Give some examples of ways a physical therapist assistant can incorporate disablement concepts into his or her documentation.

7. Look at the examples below. Determine if each would be considered an impairment in body function or structure, an activity limitation, or a participation restriction.

Taking a bath Going to school Brushing teeth Limited shoulder motion Walking in the community Going to the grocery store Ascending/descending stairs Turning a door knob Poor endurance Writing Working Poor balance Donning socks Bathing

Disablement and Physical Therapy Documentation 7

Read the following scenarios and identify the impairments, activity limitations and participation restrictions.

8. You are working with a 70-year-old male who had a total hip replacement 3 weeks ago. He is now able to move in and out of the bed independently, transfer to a chair placed at the bedside, and ambulate 25 feet with a standard walker. He wants to return to driving, golfing, and playing with his grandchildren.

9. You are working with a 10-year-old female in the school system. Her medical diagnosis (pathology) is spastic diple- gia cerebral palsy. You have been working on ambulating up and down the stairs (which she can perform with min- imum assist of 1, a quad cane, and a handrail) and increasing the speed of her gait. At the present time, she leaves her classes early so that she can make it to the next one on time, and she uses the elevator rather than the stairs.

10. Your patient is a 15-year-old who sustained a traumatic closed head injury in a motorcycle accident. He is confused and disoriented, and he requires constant supervision for his safety. He can walk and get in and out of bed with supervision. He can also ascend and descend stairs with supervision. He is unable to work.

Rebecca McKnight, PT, MS

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 9-18)

© 2018 SLACK Incorporated 9

The Physical Therapy Episode of Care

Chapter 2

After reading this chapter, the reader will be able to do the following: 1. Describe a physical therapy episode of care from point

of entry to discontinuation of services. 2. Discuss the various ways patients access a physical

therapist for care. 3. List the 6 elements of the Patient/Client Management

Model. 4. Define and describe each of the 6 elements of the

Patient/Client Management Model. 5. Discuss the roles of the physical therapist and physi-

cal therapist assistant within the Patient/Client Management Model.

6. Describe the physical therapist assistant’s responsibili- ties related to patient care, documentation, and com- munication.

Sadie had come to terms with the fact that she has mul- tiple sclerosis. After all, she had witnessed her aunt Linda, who also was diagnosed with multiple sclerosis, living a fruitful and productive life even though she had to make some changes in her daily routine. This did not, however,

keep Sadie from getting frustrated with some of the new issues she had to face. Most recently, she had been experienc- ing fatigue, which had been hindering her ability to function at work. Even more frustrating than the fatigue were the new symptoms of clumsiness affecting her arms and legs and causing her difficulty with most of her activities. Upon her neurologist’s suggestion, Sadie had been admitted to the local hospital for treatment. After returning home from the hospital, Sadie was still experiencing difficulties with her daily tasks. Her neurologist recommended that Sadie seek a physical therapist to address her coordination and balance issues. Sadie sat in front of her computer with a list of physi- cal therapists in the area and began to research each physical therapist to see whether any had experience with working with individuals with her problems.

To actively participate in the provision of physical therapy services efficiently and with confidence, you must start with an understanding of the entire physical therapy care process. This will enable you to appreciate the role that you will play in the provision of interventions and the role of your supervising physical therapist(s). Based upon this understanding, you will begin to grasp how integral communication is to the entire process and how essen- tial effective documentation is in ensuring that patients

CHAPTER OBJECTIVES

KEY TERMS Diagnosis | Episode of care | Evaluation | Examination | Intervention | Outcome | Patient/client management | Plan of care | Prognosis

Chapter 210

“receive appropriate, comprehensive, efficient, and effective quality care.”1 This chapter examines how patients access physical therapy services. We provide a general outline of components of physical therapy care throughout an episode of care. We then take a close look at the American Physical Therapy Association (APTA) Patient/Client Management Model and the roles of the physical therapist and physical therapist assistant within the components of the model. Finally, we touch on the relationship between the Patient/ Client Management Model and documentation, providing the foundation for upcoming chapters.

PHYSICAL THERAPIST SERVICES The APTA Guide to Physical Therapist Practice1 outlines

the physical therapy process by means of the Patient/Client Management Model. This model defines and describes 6 elements required to ensure that optimal physical therapy care occurs during a patient’s episode of care. These essen- tial components include examination, evaluation, diagno- sis, prognosis, intervention, and outcomes (Table 2-1)1. We will look at each of these components in more detail, but first we need to consider how patients/clients access a physi- cal therapist to receive care.

Patient Point of Entry Individuals enter physical therapy care by either self-

referral or when referred by another health care practi- tioner. Self-referral, also known as direct access, is when an individual seeks care from a physical therapist with- out first obtaining a referral from another primary care provider, such as a physician. Currently, all state practice acts allow a physical therapist to perform an evaluation and provide some form of treatment without a physi- cian referral.2 However, most states still have restrictions that limit what care the physical therapist can provide in the absence of meeting additional conditions. As of June 2016, only 18 states allow unrestricted access to physical therapy services. Unrestricted access is when there are no legal restrictions or additional conditions required of a physical therapist to provide all aspects of patient/cli- ent management. The level of patient access to physical therapy services and types of restrictions per state law can be viewed in the APTA document Levels of Patient Access to Physical Therapist Services in the States: http://www. apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/ Direct_Access/DirectAccessbyState.pdf.

In addition to self-referral, patients access a physical therapist when referred by another health care provider. Depending on state regulations, physical therapists can receive referrals from physicians, physician assistants, chi- ropractors, nurse practitioners, midwives, and dentists. Often, patients initially access physical therapy services during a hospitalization for disease or injury. At other

times, individuals will enter physical therapy care through outpatient services, home health services, or school-based services.

The Patient/Client Management Model Once an individual has accessed a physical therapist,

the therapist will initiate the episode of care through the examination/evaluation process. This process must be initi- ated prior to the provision of any interventions. During the examination, the physical therapist collects data that will be used in determining appropriate management strate- gies. The mental process of analyzing the data and making clinical decisions based upon the information is referred to as the evaluation. As part of the evaluation, the physi- cal therapist will determine a physical therapy diagnosis, the patient’s prognosis for achieving expected outcomes, and what intervention strategies will be implemented. Once interventions are initiated, the physical therapist will monitor the patient’s progress through a review of his or her outcomes. Let’s take a closer look at these elements.

Examination As indicated above, the purpose of the examination is

for the physical therapist to collect data to guide clinical decision making. An examination consists of the following 3 components: (1) history, (2) systems review, and (3) tests and measures. Patient history can be obtained from the patient or the patient’s caregiver, family, other individuals familiar with the patient’s history (eg, other health care providers, case managers, teachers, employers, significant others),1 and medical record if one is available. History data include information related to several areas, including the current condition for which the individual is seeking physical therapy services and current or past health infor- mation (Sidebar 2-1). Additionally, the physical therapist will ask about the patient’s home situation, support system, and community involvement. Patient history data allow the therapist to gain a holistic view of the individual and help to contextualize the patient’s reason for seeking physical therapy services. The information is essential for the physi- cal therapist to consider when determining the patient’s prognosis.

After obtaining a picture of the patient’s condition and concerns through history taking, the physical therapist performs a systems review. A systems review is a “hands-on examination” where the therapist performs limited exami- nation of the patient’s overall medical health by reviewing the patient’s cardiovascular/pulmonary system, integu- mentary system, musculoskeletal system, neuromuscular system, communication ability, affect, cognition, language, and learning style.3 Based on information gathered dur- ing the history and systems review, the physical therapist will select and perform appropriate tests and measures.1 Tests and measures are methods and techniques that the

The Physical Therapy Episode of Care 11

Table 2-11

Elements of the Patient/Client Management Model

Element Who/When Includes Source of Information

Purpose

Examination Performed by the physical therapist on all patients prior to provision of interventions

• History • Systems review • Tests and measures

• Medical record review

• Patient interview

• Communication with others

Provides data needed for the physical therapist to determine the plan of care

Evaluation Performed by the physical therapist in conjunction with, and based upon, the examination

• Plan of care (goals and interventions to be provided)

• Involvement of other providers

The clinical judge- ment of the physi- cal therapist based upon findings from the examination

Allows others (including the physical thera- pist assistant) insight into the anticipated level of improvement, intervention plan, and frequency and duration of services

Diagnosis Determined by the physical therapist

A label which describes the dysfunction requiring physical therapist interventions

Prognosis Determined by the physical therapist

The predicted level of improvement, treatment goals, expected outcomes, duration and frequency of treatment and interventions to be used

Intervention Done by the physical therapist or physical therapist assistant (as directed) to produce the changes in the patient’s condition

• Patient or client instruction

• Airway clearance techniques

• Assistive technology • Biophysical agents • Functional training in self-care and domestic, work, com- munity, social, and civic life

• Integumentary repair and protection techniques

• Manual therapy techniques

• Motor function

Specific interven- tions to be provided per the categories outlined by the physical therapist in the plan of care

Decrease inflam- mation, decrease pain, increase motion, improve functional abilities, etc

Outcomes Performed by the physical therapist or the physical therapist assistant

Tests and observations consistent with initial examination

Initial examina- tion and follow-up documentation

Used to deter- mine patient response to interventions and progress toward goals

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therapist uses to gather data needed to determine the diag- nosis and prognosis and to guide clinical decision making (Sidebar 2-2). Tests and measures are also used later in patient/client management to evaluate outcomes and to note patient progression.

Evaluation The physical therapist analyzes the information gathered

during the examination process and makes clinical judg- ments about the findings. This clinical decision-making process is known as the evaluation. Evaluation is a continu- ous process. It begins with the first data gathered during the history taking and undergirds all decisions made through- out the entire episode of care; however, as a component of initiation of care, evaluation is the process that the physical therapist utilizes to determine a physical therapy diagnosis and prognosis and to establish the plan of care.

Clinical decisions made by the physical therapist include whether to initiate physical therapy care and whether there is a need for other health care provider involvement. The involvement of other health care providers can include referral, consultation, comanagement, or a combination of these. A physical therapist will choose to refer a patient when the patient’s condition requires the management of a different health care provider. This might be because

the patient has a condition that falls outside of the scope of practice of the physical therapist or it could be because the patient’s physical therapy needs fall outside of the physical therapist’s personal scope of practice (knowledge, abilities, or experience). The following are examples of each situation:

• Outside of a physical therapist’s scope of practice º During the examination, the physical therapist notes

findings consistent with congestive heart failure. The therapist refers the patient to a cardiologist so the patient can receive the necessary medical care.

Sidebar 2-1 Categories of Information Gathered in

History Portion of the Examination • Activities and participation • Current condition(s)/chief complaint(s) • Employment/work (eg, job, school, play) • Family history • Functional status and activity level • Health restoration and prevention needs • General demographics (eg, age, sex, race) • General health status • Growth and development • Living environment • Medical/surgical history • Medications • Systems review via medical chart review

including other clinical tests • Social history • Social/health habits (past and current)

Sidebar 2-2 Categories of Tests and Measures Used by

Physical Therapists • Aerobic capacity/endurance • Anthropometric characteristics • Assistive technology • Balance • Circulation • Community, social, and civic life • Cranial and peripheral nerve integrity • Education life • Environmental factors • Gait • Integumentary integrity • Joint integrity and mobility • Mental functions • Mobility • Motor function • Muscle performance • Neuromotor development and sensory

processing • Pain • Posture • Range of motion • Reflex integrity • Self-care and domestic life • Sensory integrity • Skeletal integrity • Ventilation and respiration • Work life

The Physical Therapy Episode of Care 13

• Outside of a physical therapist’s personal scope of practice

º A physical therapist’s examination reveals a vestibu- lar disorder. Although interventions for vestibular disorders fall within the physical therapy scope of practice, the therapist is aware of another therapist in the area who specializes in vestibular disorder therapy and, therefore, refers the patient to ensure that he or she receives optimal care.

Even when the physical therapist chooses to refer a patient to another care provider for services, the physical therapist is still obligated to determine whether the patient is appropriate for care and, in both scenarios above, it is possible that the therapist might retain some patient care management responsibilities. In the scenario with the patient referred to the cardiologist, the physical therapist might choose to work with the patient on energy conserva- tion techniques and modified activities of daily living while waiting for the cardiologist report. In the second scenario, the patient might also have other physical therapy problems for which the initiating physical therapist has more experi- ence and is a more-qualified professional to address. In this case, the therapists would divide the patient manage- ment based on their levels of expertise and should closely collaborate. This would be an example of comanagement described below.

In some cases, the physical therapist may choose to retain care of the patient but consult with another pro- vider due to the nature of the condition. Examples of other providers with whom the physical therapist might consult include a physician, a dentist, a nurse practitioner, a psy- chologist, an occupational therapist, or even another physi- cal therapist. It is appropriate for the physical therapist to seek the advice of any provider who can provide insight that would be beneficial to the patient. The following are 2 examples of incidents when a physical therapist consults with another provider:

• A physical therapist consults with another discipline. º A physical therapist is working with a patient with

long-term activity limitations and participation restrictions due to a cerebrovascular accident. The patient demonstrates cognitive and behavioral defi- cits that impact the patient’s ability to participate in physical therapy. The therapist consults with a neuropsychologist to determine the best strategies for patient management and to optimize interventions and ensure that the best care is provided.

• A physical therapist consults with another physical therapist.

º A physical therapist’s examination reveals a vestibu- lar disorder. Although interventions for vestibular disorders fall within the scope of practice of a physi- cal therapist, the therapist does not have any expe- rience with vestibular disorders. The patient lives in a rural area and there are no therapists in the

area with expertise in the management of patients with vestibular disorders. To ensure that the patient receives optimal care, the physical therapist consults with a physical therapist in another area who is a certified vestibular specialist.

Comanagement is a common situation in inpatient facilities and with pediatric clients. It occurs when the physical therapist shares responsibility for patient manage- ment with providers from other disciplines or with another physical therapist (as in the scenario described above). Comanagement requires collaboration and strong commu- nication due to the shared responsibility for patient care. Examples of comanagement include interdisciplinary care that is provided in an inpatient rehabilitation environment or with school-based therapy services.

When the physical therapist determines that it is appro- priate to initiate care, the therapist may directly provide some or all of the interventions or may choose to direct a physical therapist assistant to provide selected interven- tions. In the event that the physical therapist directs compo- nents of the intervention to the physical therapist assistant, the physical therapist remains responsible for all aspects of the physical therapy episode of care and is accountable for the actions of the physical therapist assistant(s).

Prior to initiating interventions, the physical therapist established a plan of care. The plan of care is developed in collaboration with the patient and is based on the examina- tion, evaluation, diagnosis, and prognosis. As indicated in the APTA Defensible Documentation materials, the plan of care includes the following3:

• Overall goals stated in functional, measurable terms that indicate the predicted level of improvement in function.

• A statement of interventions/treatments to be provided during the episode of care.

• Duration and frequency of service required to reach the goals.

• Anticipated discharge plans (may be part of the prog- nosis or written separately).

The physical therapist’s plan of care must include suc- cinct, “measurable, functionally driven, and time limited”1 goals. Goals serve as the tool to which outcomes are com- pared. This allows for the assessment of the effectiveness of the plan of care and the determination of the patient’s progress. A well-written plan of care also delineates the interventions, parameters for each intervention, purpose of the interventions, progression parameters, and, if indi- cated, precautions.

Intervention Once the plan of care has been established, direct inter-

vention can begin. As noted earlier, physical therapists may choose to provide the interventions or may direct that inter- ventions be provided by a physical therapist assistant. The Guide to Physical Therapist Practice defines interventions

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as “the purposeful interaction of the physical therapist with an individual—and, when appropriate, with other people involved in the individual’s care—to produce changes in the condition that are consistent with the diagnosis and prognosis.”1 Interventions should focus on optimizing the individual’s function. Physical therapy interventions fall into the following 9 categories1:

• Patient or client instruction (used with every patient and client)

• Airway clearance techniques • Assistive technology • Biophysical agents • Functional training in self-care and domestic, work,

community, social, and civic life • Integumentary repair and protection techniques • Manual therapy techniques • Motor function training • Therapeutic exercise

Outcomes As physical therapy interventions are initiated, the

patient’s progress toward the established goals is monitored through the collection of outcomes data. Outcomes data are gathered using tests and observations related to the patient’s response to physical therapy interventions. The data (outcomes) are then compared to the initial findings to determine what progress, if any, has occurred. Since outcomes data include a variety of types of data some outcomes data should be noted at every patient encoun- ter. Observations of the patient’s functional status, motor control, and more should be made and documented. Other tests are more time consuming and complex and should be scheduled at specific times that correlate with established goals, legal requirements (state practice acts), facility policy, and/or third-party payer mandates. At various times within an episode of care, re-examination may occur to formally document the patient’s status and progress, or lack thereof. Based on the findings from the re-examination, the physi- cal therapist may revise the plan of care.

Discharge/Discontinuation of Services In the plan of care, established as a result of the initial

examination and evaluation, the physical therapist will address discharge plans. Depending on several variables (eg, the care setting, the established goals, the patient’s progress, the patient’s prognosis), the plan may include transfer to another therapy service in another care setting (eg, acute rehab, skilled nursing, outpatient, home health). When established goals are met, discharge from an episode of care occurs. Additionally, discontinuation of physi- cal therapy services may occur without established goals being achieved. When this happens, the physical therapist should document why the established goals were not met.3 Upon discharge or discontinuation, the patient/client may

be given a home exercise program or may be placed on a maintenance therapy program to maintain maximum functional capabilities in the absence of skilled therapeutic intervention. The establishment of a home exercise pro- gram, whether during the episode of physical therapy care or at the conclusion of services, should be a part of the plan of care established by the physical therapist.

PHYSICAL THERAPIST AND PHYSICAL THERAPIST ASSISTANT ROLES

The APTA Direction and Supervision of the Physical Therapist Assistant4 clearly outlines the roles that the physical therapist and physical therapist assistant perform within the Patient/Client Management Model. The physical therapist is the recognized professional who establishes, guides, and directs all aspects of the provision of physical therapy services. It is the responsibility of the physical ther- apist to interpret referrals; perform the initial examination and evaluation; establish the physical therapy diagnosis, prognosis, and plan of care (including goals and discharge plan); and determine which interventions require the clini- cal decision-making skill of a physical therapist and which interventions can be provided by a physical therapist assis- tant. In addition, the physical therapist is responsible for the re-examination of the patient and the revision of the plan of care when indicated. The physical therapist is also directly responsible for ensuring appropriate documentation for all physical therapy services.4

As a physical therapist assistant, your role in patient care activities falls within the intervention and outcomes portions of the Patient/Client Management Model. You will implement selected interventions of the plan of care as directed by the physical therapist. You may provide spe- cific interventions from any of the 9 intervention categories listed previously. You must be able to utilize sound clinical reasoning to determine the patient’s readiness to engage in the selected interventions and the patient’s response(s) to the intervention(s) being providing. You will need to deter- mine when to consult with the physical therapist about the patient’s status and progress or lack thereof. Throughout the provision of interventions, you will also need to perform appropriate tests to collect outcomes data to determine the patient’s appropriateness to engage in selected interven- tions and to provide information useful in determining the patient’s progress toward the goals established by the physi- cal therapist. As a physical therapist assistant, you will need to modify details of the physical therapist’s treatment pro- gram to facilitate patient progression within the established plan of care or to ensure the patient’s safety and comfort while engaged in the interventions being provided.5

Whether interventions are provided by the physical therapist directly or by a physical therapist assistant, the physical therapist remains responsible for all aspects of the physical therapy services. As a physical therapist assis-

The Physical Therapy Episode of Care 15

tant, you will be responsible for only providing the patient care interventions directed to you by the patient’s physical therapist. You will share the responsibility with the physical therapist to ensure that you only provide patient care inter- ventions within your education and skill level and within legal parameters for the state in which you practice.6-8 It will also be your responsibility to clearly and accurately document all patient care activities that you provide.4,8

For the provision of physical therapy services to be efficient and effective, a positive working relationship must exist between the physical therapist and the physical therapist assistant. This type of relationship is character- ized by trust and mutual respect, as well as an appreciation for individual differences. A hallmark of a good working relationship is excellent communication.9,10

COORDINATION, COMMUNICATION, AND DOCUMENTATION

To ensure optimal outcomes from physical therapy ser- vices, it is imperative that appropriate coordination of ser- vices and communication related to those services occur. Both components can be facilitated through, and should (at a minimum) be outlined in, concise documentation. Collaboration of services includes working with a variety of health care providers and, most importantly, the patient and the patient’s family/support structure. Collaboration only occurs in the presence of rich communication. To be able to function within the health care delivery system, you will need to effectively communicate with other members of the health care delivery team. Effective communication includes appropriate verbal and nonverbal communication, as well as accurate documentation. Accurate and effective documentation will provide the foundation upon which all clinical activity occurs. Documentation of the patient’s epi- sode of physical therapy care occurs initially with the initial examination/evaluation and throughout the episode of care with interim notes including treatment session notes and re-examination/re-evaluation notes. The final documenta- tion is a discharge summary that provides a summary of the entire episode of care, a description of the patient’s status at the time of discharge, and information regarding any additional recommendations for follow-up care (Table 2-2).

Now that we have looked at the Patient/Client Management Model and we have a clear picture of how a patient transitions through an episode of care, let’s take a closer look at how documentation plays a part within the provision of physical therapy services.

REFERENCES 1. American Physical Therapy Association. Guide to Physical

Therapist Practice 3.0. APTA Website. http://guidetoptprac- tice.apta.org/content/1/SEC2.body. Updated August 1, 2014. Accessed October 24, 2016.

2. American Physical Therapy Association. FAQ: direct access at the state level. APTA Website. http://www.apta.org/ StateIssues/DirectAccess/FAQs/. Accessed July 7, 2017.

3. American Physical Therapy Association. Defensible docu- mentation: components of documentation within the patient/ client management model. APTA Website. http://www.apta. org/Documentation/DefensibleDocumentation/. Accessed January 17, 2017.

4. American Physical Therapy Association. Guidelines: Physical Therapy Documentation of Patient/Client Management. BOD G 03-05-16-41. http://www.apta.org/ uploadedFiles/APTAorg/About_Us/Policies/Practice/ DocumentationPatientClientManagement.pdf. Updated December 14, 2009. Accessed July 7, 2017.

5. American Physical Therapy Association. Direction and supervision of the physical therapist assistant. HOD P06- 05-18-26. http://www.apta.org/uploadedFiles/APTAorg/ P r a c t i c e _ a n d _ P a t i e nt _ C a r e / Move m e nt _ Sy s t e m / MovementSystemSummit_Prereadings.pdf Accessed July 7, 2017.

6. American Physical Therapy Association. A Normative Model of Physical Therapist Assistant Education. Alexandria, VA: American Physical Therapy Association; 2007.

7. American Physical Therapy Association. Minimum required skills of physical therapist assistant graduates at entry- level. BOD G11-08-09-18. https://www.apta.org/upload- edFiles/APTAorg/About_Us/Policies/BOD/Education/ MinReqSkillsPTGrad.pdf. Accessed January 14, 2017.

8. American Physical Therapy Association. Standards of ethical conduct for the physical therapist assistant. APTA Website. https://www.apta.org/uploadedFiles/APTAorg/About_Us/ Policies/Ethics/CodeofEthics.pdf. Accessed January 14, 2017.

9. Holcomb S. Recipe for effective teamwork: why some PT/ PTA pairings thrive, to patient’s ultimate benefit. PT Magazine. February 2009. http://www.apta.org/PTinMotion/2009/2/. Accessed January 15, 2017.

10. American Physical Therapy Association. PT/PTA teamwork: models in delivering patient care. APTA Website. http:// www.apta.org/SupervisionTeamwork/Models/. Accessed January 15, 2017.

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Table 2-2 Episode of Care Documentation

Documentation Notes

Written By When Includes Purpose

Initial Physical therapist

At the initiation of an episode of care prior to provision of any interventions

• A description of the patient status

• Findings from the examination

• The physical therapist’s evaluation

• The physical therapist’s plan of care

Provides data needed for the physical therapist to determine the plan of care

Interim̶ Treatment Session

Physical therapist or physical therapist assistant who provided the interventions

At every patient care encounter

Interim̶ Re-examination/ Re-evaluation

Physical therapist

Discharge Summary

Physical therapist

At the end of an episode of care

The Physical Therapy Episode of Care 17

REVIEW QUESTIONS 1. Create a concept map that depicts an episode of physical therapy care from the point of entry through discharge.

2. Describe how patients access physical therapy care. Provide 3 examples of how a patient might gain access to a physical therapist.

3. Define and describe the 5 elements of the Patient/Client Management Model.

4. Next to each component of the Patient/Client Management Model, indicate whether the physical therapist (indicate with PT), the physical therapist assistant (indicate with PTA), or both participate(s) in that process.

Examination Evaluation Diagnosis Prognosis Intervention Outcomes

5. Describe the types of decisions made by the physical therapist during the evaluation process.

6. List the essential components of a plan of care.

7. What is the importance of outcomes measures in patient/client management?

8. Describe the role of the physical therapist assistant in the physical therapy process. List the responsibilities of the physical therapist assistant within that role.

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APPLICATION EXERCISES I. Reference the physical therapy practice act for your state of residence for language regarding direct access. Are there

any restrictions or provisions related to direct access in the practice act? If so, what are they?

II. Reference the physical therapy practice act for your state or residence for language regarding documentation. What are the responsibilities of the physical therapist assistant regarding documentation? What, if any, are the restric- tions placed upon the physical therapist assistant regarding documentation? Compare your state practice act with a practice act from a different state. What are the similarities? What are the differences? Discuss how these differing requirements can impact the operation of physical therapy in a variety of settings.

III. Interview a friend or family member who has received physical therapy services. Ask him or her to describe how he or she entered the physical therapy care system. Ask him or her to describe the process as he or she remembers it. Compare the information that you receive with the experiences reported by other interviews performed by your classmates.

Mia L. Erickson, PT, EdD, CHT, ATC

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 19-28)

© 2018 SLACK Incorporated 19

Reasons for Documenting

Chapter 3

After reading this chapter, the reader will be able to do the following: 1. List the major reasons for documenting. 2. Identify the types of patient data found in a medical

record. 3. Explain how clinical decision making can be articu-

lated in a medical record. 4. Explain the role of the physical therapist assistant in

the clinical decision-making process. 5. Describe the reasonable and necessary criteria. 6. Differentiate between skilled care and maintenance

therapy. 7. Explain how to document the patient’s response to

treatment. Imagine that you are working as a physical therapist

assistant in a small outpatient clinic. For the last 6 weeks, you and your supervising physical therapist have been working with a 35-year-old man who was recently involved in a motor vehicle accident. He sustained a concussion and multiple fractures including the left femur and radius.

Initially, he was unable to bear weight through either extremity and required a wheelchair as his primary mode of mobility. He had significant loss in range of motion and was unable to perform self-care, home/community mobil- ity, and work activities. He has been making excellent progress and is now able to walk using one crutch and has resumed most of his normal activities of daily living. The physical therapist with whom you are working receives a call from the patient’s insurance company stating that they are going to deny payment for physical therapy services. To have additional therapy services approved, the clinic must submit adequate documentation showing that further skilled services are medically necessary.

LEGAL AND ETHICAL RESPONSIBILITY As a physical therapist assistant, documentation will be

one of the most important things you do. In health care, documentation provides a legal record of care, facilitates communication among health care providers, and serves as a source of information for clinical research.1 Both state and federal laws mandate recording health care provided to an individual. Facilities and organizations providing com-

CHAPTER OBJECTIVES

KEY TERMS Maintenance therapy | Medicaid | Medicare | Objective data | Reasonable and necessary criteria | Reimbursement | Skilled care (services) | Subjective data

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ponents of the Patient/Client Management Model discussed in Chapter 2 have policies pertaining to documentation.

Medical records are legal documents, and any entry you make into the medical record becomes part of that legal document; therefore, it is important that your docu- mentation is accurate, legible, and completely depicts the patient’s condition and intervention provided. Be aware that a patient’s medical records can be subpoenaed and used as evidence in a variety of legal matters. These include motor vehicle accidents, workers’ compensation or dis- ability claims, and malpractice suits brought against you or other health care providers. In malpractice lawsuits, documentation is the clinician’s first line of defense. Good documentation can stop a lawsuit in its tracks, and poor documentation can be “powerful evidence in support of a suit, even when the accusations are frivolous.”2 Consider the following as a rule of thumb: “If it isn’t documented, it didn’t happen.”

In addition to legal obligations, maintaining accurate, timely, well-written patient records is considered one of your ethical duties as a physical therapist assistant. The Standards of Ethical Conduct for the Physical Therapist Assistant states, “Physical therapist assistants shall ensure that documentation for their interventions accurately reflects the nature and extent of the services provided.”3

REIMBURSEMENT Reimbursement means “to pay back” for a service that

has been provided.4 In health care, either the patient or a third party (eg, an insurance company, government agency such as Medicare) pays for services. Medicare and Medicaid began requiring documentation for reimbursement in phys- ical therapy in the 1960s.1 Soon after that, Medicare began a restructuring process and started requiring rehabilitation facilities to not only maintain documentation, but also to submit the records for review by Medicare auditors. The purpose of these reviews was to determine whether physi- cal therapy services provided to Medicare beneficiaries met requirements for reimbursement. As the US health care delivery system has evolved over the last decades, third- party reimbursement from all payers has become another reason for documenting patient care. Reimbursement from third-party payers can be dependent upon documenta- tion in that, to receive payment, the documentation must support the services provided. Consider the patient case discussed earlier in this chapter. Continuation of his physi- cal therapy benefits is based largely on how well the clini- cians have documented his improvement and the need for ongoing services. Communication with third-party payers through appropriate documentation has been called the “key to securing reimbursement.”5

RECORD PATIENT DATA One of the primary reasons for documenting physical

therapy services is to maintain a record of patient data. These data should reflect the entire episode of patient care, from start to finish, beginning with an initial examina- tion performed by the physical therapist and ending with a discharge summary. During the initial examination, the physical therapist collects and records data pertaining to the patient’s current condition. These include both subjec- tive and objective information. The history-taking portion of the initial examination provides the physical therapist with subjective information. It includes what the patient, family member, or caregiver says pertaining to the patient’s condition. History of the current condition, mechanism of injury, date of onset, and history of a similar problem are all examples of subjective information gathered during the initial examination. Other subjective information collected at this point should include a thorough medical history, a review of the patient’s living situation, chief complaints (including his or her activity limitations and restrictions in his or her ability to participate in normal life roles or tasks), and his or her goals for physical therapy. Information relat- ed to the patient’s functional status can be gleaned through direct questioning by the physical therapist or through the use of patient self-report measures. Self-report measures are questionnaires that ask the patient to rate his or her abil- ity to perform functional tasks. Data from these question- naires provide the physical therapist and physical therapist assistant with information about patient functioning from the patient’s perspective.

In addition to subjective information, documented data should include objective information or results from the systems review and objective tests and measurements. Examples of these types of objective data include mea- surements of range of motion, strength, sensation, girth, balance, and functional status (eg, walking, transferring, performing activities such as self-care and home manage- ment). While data from self-report measures of function are often considered part of the subjective information, data from observable patient performance of a functional task are considered objective information. Objective data pro- vide additional information to help identify and measure the extent of the patient’s impairments, activity limitations, and participation restrictions. Self-report measures, obser- vation of functional performance, and performance-based measures can be used together to provide information about the patient’s functional status.

A record of the patient’s functional status provides particularly valuable information regarding the effects of the disease or injury on the patient’s normal activities and lifestyle. Furthermore, individuals reviewing medical records deem the patient’s functional status as being more meaningful than documentation of impairments alone.

Reasons for Documenting 21

Although impairment data are necessary, documenting function, including activity limitations and participation restrictions, provides reviewers with specific contextual information regarding the impact of injury on the patient’s lifestyle.

Both subjective and objective data provide physical therapists and physical therapist assistants with baseline measurements with which future measurements can be compared.6 Information taken from the patient, as well as objective measurements, are not only documented during the initial examination, but also during subsequent physical therapy sessions. In subsequent sessions, data are recorded in the form of treatment or interim notes, progress reports, or, in the case of discharge from physical therapy services, a discharge summary. In any event, any data collected after the initial examination should be recorded. It will be compared with that found in the initial examination. These comparisons allow the medical record to reflect both sub- jective (patient comments) and objective (data from tests/ measurements) changes in the patient’s status.

Records of patient data are important to others involved in the patient’s care. Health care providers such as physi- cians, nurses, occupational and speech therapists, and case managers, among others, are often interested in a patient’s status and therefore might examine physical therapy docu- mentation. Physicians might be interested in how far a patient can walk prior to deciding on discharge from the hospital. Nurses might be interested in a patient’s ability to transfer out of the bed, whereas case managers might want to examine equipment needs or return-to-work sta- tus; therefore, documentation serves as a useful tool for facilitating communication across disciplines. In addition to other health care providers, third-party payers are inter- ested in records of patient data.

Accurate records of patient data also aid in our ability to analyze and study patient outcomes. Outcomes are defined as the end result of patient/client management.7 Collection of outcomes data is an important area of physical therapy practice, and it is necessary to support and validate the physical therapy services provided. Outcomes data are also necessary to support evidence-based practice. For example, analysis of patient outcomes can allow us to determine the effectiveness of physical therapy interventions. Use of standard terms, such as those provided by the International Classification of Functioning, Disability and Health in our data collection can also support outcomes data collection.8

RECORD PATIENT CARE Your documentation will also serve as a record of the

care you provided to your patients. Interventions are divided into 3 categories. The first is procedural interven- tions. These are considered direct interventions and include those related to direct patient care, such as modalities, physical agents (eg, ice, heat), massage, stretching exercises, strengthening exercises, gait training, and transfer train-

ing. The second category is coordination and communica- tion. This is more indirect but is still an important aspect of patient care. Examples include communicating with family members, other health care providers, or any other individual involved in the care of the patient. Phone calls, relevant conversations regarding the patient, and collabora- tion with other providers, including the physical therapist, must also be documented as part of the patient’s record. The third category is patient/client-related instruction. This category includes teaching that was provided to the patient, family, or caregiver as well as his or her understanding or response to the teaching. Both physical therapists and physical therapist assistants are responsible for accurately recording services provided in each of these 3 categories.

Documented interventions serve to support treatment that was billed for a given date of service. Third-party pay- ers may perform a documentation audit to assure that the treatment provided and billed is supported by the clini- cian’s documentation. Inaccurate or incomplete documen- tation that does not support daily charges may be construed as fraud or abuse and must be avoided.

Accurately recording patient care is also necessary where electronic billing and documentation software are integrated. In these situations, the patient’s charges are generated based on the interventions that the therapist provided and documented in the day’s note. Incomplete or inaccurate documentation may generate too many or too few charges to the patient’s account. Additionally, a patient may be charged for a service not provided. Again, these inconsistencies can prompt an audit, which can result in fines, repayment, or accusations of abuse or fraud, so it is very important that the record accurately reflects all aspects of the care provided to the patient.

Another reason for documenting patient care is to keep a record for other therapists in the event of your absence. In the event of an emergency where a physical therapy pro- vider is unable to come to work, another physical therapist or physical therapist assistant should be able to pick up the record and provide the appropriate patient care. This main- tains consistency of care across providers.

In addition to specific patient care provided, it is impor- tant to document the patient’s response to treatment. This can be done in a variety of ways. Thinking in terms of dis- ablement, response to treatment should provide informa- tion as to how the interventions are positively or negatively influencing the patient’s impairments, activity limitations, or participation restrictions. For example, a physical thera- pist could record the following:

Dynamic balance training and lower-extremity strength- ening exercises have allowed the patient to improve balance as measured by the Berg Balance Scale and the patient is now at less risk for falls.

In this example, the physical therapist documented the patient’s overall response to treatment in terms of impair- ments (improved balance) and function (less risk of falls). Consider the following example written by a physical thera- pist assistant:

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Upon arrival, the patient was complaining of 6/10 pain in the right buttock and leg and was having difficulty sit- ting. Following modalities and extension exercises, the pain decreased to 3/10 and was no longer radiating down the patient’s leg.

When the response to treatment is documented in this manner, the note reflects how the interventions brought about a change in the patient’s status, and it supports treat- ment effectiveness. Being specific in the patient’s response can show a third-party payer how the patient is improving and how the treatment is influencing impairments and function.

Documenting response to treatment can serve as a record of unexpected events that may have taken place and your response. For example, when a patient returns for a therapy visit and has increased soreness after performing his home exercise program, the physical therapist assistant can make adjustments within the plan of care to lower the exercise intensity. Patient complaints should be document- ed, and the therapist’s actions in response to the patient’s complaints should also be documented. The therapist’s response to an adverse event may not always be directed toward the patient. Consider the following example:

A physical therapist goes to see a patient 4 weeks post total knee arthroplasty for a re-evaluation in the patient’s home. The patient is complaining of severe knee pain, swell- ing, nausea, redness, elevated skin temperature, and white drainage from the incision. Upon observation, the physical therapist believes that the patient has an infection and calls the physician.

The physical therapist should document the events that took place, the observations, any assessments, and his or her action. Documenting response to treatment and your actions, when appropriate, helps to show patient manage- ment and clinical decision making in response to positive or negative events.

PROVIDE PROOF THAT CARE IS REASONABLE AND NECESSARY

Our documentation must provide evidence that physical therapy services are reasonable and necessary. The Centers for Medicare & Medicaid Services has set forth the follow- ing criteria that need to be met for services to be considered reasonable and necessary9:

• “The services shall be considered under accepted stan- dards of medical practice to be a specific and effective treatment for the patient’s condition.”

• “The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effec- tively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist.”

• “While a beneficiary’s particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary’s diagnosis or prognosis can- not be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treated the illness or injury, or whether the services can be carried out by nonskilled personnel.”

• “The amount, frequency, and duration of the services must be reasonable under accepted standards of prac- tice. The contractor shall consult local professionals or the state or national therapy associations in the devel- opment of any utilization guidelines.”

Documentation to justify reasonable and necessary services includes initial documentation that describes the patient’s pathology, impairments, activity limitations, and participation restrictions. The documentation includes a description of how the impairments have led to limitations in a patient’s activity level or restrictions in a patient’s ability to participate in normal life roles or tasks. Documentation outlines a specific plan of care or interventions aimed at addressing these limitations, and it includes ongoing reas- sessments to show changes in status. The documentation must convey how the interventions are influencing the patient’s condition. Furthermore, the documentation must show how the interventions provided required the unique and complex skills or decision making of a therapist. Finally, the frequency and duration of services should be consistent with what would be considered appropriate for the case.

In most cases, the physical therapist provides evidence that services are reasonable and necessary in the initial documentation. The physical therapist assistant, however, plays an important role in recognizing when the interven- tion is no longer reasonable and necessary. For example, intervention may no longer be reasonable and necessary if any of the following occurs: (1) the patient has met all of the goals that have been established by the physical therapist; (2) the patient is no longer benefiting from the interven- tion; or (3) the services can be carried out through home exercise instructions or by untrained personnel. Treatment might also exceed the reasonable and necessary criteria if a patient, family member, or caregiver has unrealistic expectations for recovery.10 Documentation showing objec- tive, comparative data can help to provide evidence that a patient is progressing toward the goals stated in the plan of care. Documentation can then further support the need for subsequent or continued interventions under the reason- able and necessary criteria, or it can provide justification for discontinuing physical therapy services.

PROVIDE PROOF OF SKILLED CARE Medicare has provided definitions for skilled care and

documentation criteria.11 When determining if a service is skilled, it is always important to first consider the service

Reasons for Documenting 23

being provided and whether it reaches a level of complex- ity that it must be carried out by a therapist or under the supervision of a therapist for both safety and effectiveness. As stated in the previous section, the patient’s medical con- dition is a valid factor in determining if skilled services are needed; however, it is never the only factor.

There may be times when an unskilled service could be considered a skilled service. This is the case when a patient’s medical condition, comorbidities, or complicating factors are such that the service should be provided or supervised by a therapist for safety and effectiveness. Consider passive exercises for example. In some cases, passive exercise would be considered unskilled; however, if a patient presents with a humeral fracture and requires passive elbow exer- cises, then, due to the condition, the intervention would be considered skilled. Unskilled services are often known as maintenance therapy. Maintenance therapy services can be provided by a nonlicensed individual, such as a family member or caregiver who has had some training from a skilled professional, or by the patient through independent home exercises. Medicare and other third-party payers do not reimburse for maintenance services.12

Documentation in all cases must be thorough enough to show a reviewer that the services were skilled. The Medicare Benefit Policy Manual outlined documentation require- ments to support skilled care determinations.11 According to these guidelines, there should be sufficient documenta- tion to help a reviewer determine the following: (1) the service requires the skills of a therapist to be considered safe and effective; (2) the service is reasonable and necessary and consistent with the nature and severity of the illness or injury, the patient’s medical needs, and accepted standards of practice; and (3) the service is appropriate in terms of duration and quantity and is designed to meet a document- ed therapeutic goal. In addition, the medical record should provide thorough documentation of the history and physi- cal examination pertinent to the patient’s care (including response to treatment from previously administered skilled interventions), the skilled services provided to the patient, the response to the skilled services provided during the current visit, the plan for future care based on the rationale of prior results, a rationale that explains the need for skilled service in light of the condition, the complexity of the services provided, and any other pertinent patient charac- teristics that would support the need for skilled services.11

These documentation requirements state that the patient’s record should be accurate and specific in docu- menting the patient’s response to skilled care, avoiding vague and subjective descriptions such as “tolerated treat- ment well,” and “continue with plan of care” since these phrases do not adequately describe the patient’s response in objective terms.11 Rather, requirements state that objective measurements of physical outcomes and/or a clear descrip- tion of the patient’s response(s) that occurs as a result of the skilled service should be provided. This allows for all con- cerned to be able to follow the results of the skilled services provided.11