Month: June 2019

Point of Service Documentation (First of a 2-part series), By Mahta Mirhosseini, Therapy Resource

Traditionally, therapists have approached treatments and documentation in a compartmentalized fashion; a hands-on treatment session was provided, then documentation was done after the session was over, often times at the end of the day. With increasing use of technology and EMR software in healthcare, you may be hearing more talk about Point of Service documentation in our therapy settings. Some therapists wonder whether POS documentation can be done effectively, or if it may take quality treatment time away from patient care. Here, we discuss how POS charting can be an effective adjunct to the therapeutic process when it is done correctly.

• Think of when you were in your therapy school, did you wait till class was over to take notes? It is very similar to our therapy sessions. When you document during treatment, you can ensure that your documents are more accurate and detailed. POS documentation helps to include details that may otherwise be forgotten by end of the day.
• Do you find yourself overwhelmed at the end of the day trying to complete all your evals, encounter notes, or recert documents? POS approach helps the clinician get documentation completed as they go on throughout the day, thereby reducing end of day documentation stress.
• Do you have lots of chicken scribble on your daily activity schedule when recording patient levels and measurements? Our field is driven by objective tests and measures. POS documentation allows therapists to take detailed notes while collecting data during the session, therefore establishing and advancing appropriate goals in real-time. In fact, using EMR for POS data collection may trigger the therapist to perform additional testing to ensure that all relevant areas are addressed.
• Do you worry that POS documentation may affect relationships and quality connections with our residents? Our patient population has been seeing their physicians and healthcare professionals take notes using technology. You might even say that they have come to expect to see their providers actively capture data. The key is to engage your patients in that process and find a balance of documenting data while fostering an active and engaged therapeutic session.

Optima‘s point of service documentation solution is called Point of Care (POC), and unlike its traditional desktop Optima counterpart, POC is designed with the treating therapist in mind. Many of our therapy programs have been reporting great success using Optima’s POC to render point of service documentation. Stay tuned for our next POS documentation post which highlights efficient documentation tools that exist only in Optima’s mobile POC. If you would like to get more information on these tools before the next post, please reach out to me or your local therapy resource.

Deciding the Principle Medical Diagnosis, By Lori O’Hara, MA, CCC-SLP

Although the PDM only affects therapy buckets, determining the most appropriate diagnosis to put in the first position is an IDT Decision. It is meant to reflect the condition that most strongly explains the reason the patient needs to be skilled in the SNF, and sometimes that is not necessarily the condition for which they need rehabilitation (although it will be often!) The DOR and the therapy team should discuss the reasons the patient needs any therapies they’re receiving, and then the DOR discusses that with the IDT to reach a decision.

Here are few decision making examples:

• A patient admits who had a hip replacement, and then while in the acute hospital had a stroke. Both the hip fracture and the CVA are high-needs conditions and either could legitimately be considered the principle medical condition. When this is true, the facility is allowed to select the best prioritization. In this case, selecting the hip replacement is the best choice. While this does mean that we are opting to miss out on a neuro condition for the SLP case mix index, the benefit to the facility is greater from the hip fracture diagnosis. The patient will still need all the aggressive therapy that comes with those two conditions, so selecting the one that aligns best reimbursement with the amount of resources the patient needs is perfectly fine when it’s clear that the choice is well-supported in the record.
• A patient admits with ulcerative colitis. The patient is on immunosuppressants and close diet monitoring. The patient has suffered significant muscle wasting and is severely debilitated. The patient also has a history of Parkinson’s disease for which they’re receiving a Sinemet regiment that is unchanged in three years. While Parkinson’s would land in a more advantageous clinical category (Acute Neuro) than the ulcerative colitis (Medical Management), that decision is not consistent with the CMS requirement that the principle medical diagnosis reflect the reason the patient needs to be in a SNF. So Parkinson’s disease should not be in the first position, but should be listed as a diagnosis in a later slot.
• A patient admits for pneumonia and also has a fractures of the 4^th toe. The patient is still on antibiotics, requires supplemental oxygen and has an order for a follow-up x-ray. In this instance, while the impact of a toe fracture will certainly need rehabilitation, the patient’s management for pneumonia requires markedly more resources and interventions. So in this instance while the toe fracture would create a more financially advantageous case mix impact, it cannot be validly reported as the principle medical condition.