It is sometimes difficult to document skilled care when the primary intervention we are needing for a patient is the fitting or fabrication of a device or equipment for which we must rely on a vendor. In these cases, what’s the best strategy for setting goals and frequency of visits? Here are some points to consider when making that decision.
- Goals must always be for the patient and/or caregiver, never the clinician. Goals for the therapist to set an appointment with a vendor or complete paperwork or an assessment are not patient-centered and not appropriate for reimbursement.
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- In these circumstances, the goal should be related to the outcome of the appointment with the vendor or the result of the assessment. For example,
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- Patient to sit for 1-2 hour increments in custom wheelchair with head and trunk in midline, pelvis level, feet supported in 90 degrees of dorsiflexion, and upper extremities supported so that glenohumeral joint is in neutral so that the patient may maintain trunk and lower limb ROM, participate in conversation and activities in the community, and manipulate call light.
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- To achieve this goal, the patient may need an appointment with a w/c vendor, the therapist will need to document an assessment of the patient’s seating needs and strategies attempted, and both the vendor and therapist may need to complete necessary paperwork to ensure payment. These activities may be documented in the Plan section to a note and in the Objective section of a note as they are completed.
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- Patient to swallow safely in order to meet nutritional needs by mouth and participate in meals and food-related activities in the community.
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- To achieve this goal, the patient may need a modified barium swallow with an external vendor. The SLP may also need to complete multiple swallow trials. These efforts should be documented in the Objective section of the note. If the results of these efforts indicate the goal is not realistic, then the goal should be modified to meet the patient’s capacity.
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Please let us know what other questions you may have. Email us at Compliance@InfinityRehab.com
