While it’s common knowledge that therapy services are essential in improving patient outcomes and maximizing independence, it’s critical to understand how to document therapy treatment in a manner which demonstrates that value. We covered some of this before in our Therapy Documentation 101 article. Here, we’ll dive into documenting interventions performed and progress toward goals. With our tips and tools, your documentation can be both efficient and compliant.
Interventions, or strategies as they are also called, include procedures and modalities that help the patient/therapist team to achieve their goals. You can think of these as the steps. For example, if you want to learn how to juggle clubs for a party, you might start by (1) getting instruction about juggling, (2) performing exercises to improve your hand-eye coordination, (3) practicing using soft balls, then (4) practicing juggling clubs. Each of the numbered steps would be an intervention that would lead you to your goal of successfully juggling clubs at the party.
Establishing a therapy intervention in most medical settings requires physician approval in the form of a signed plan of care or signed verbal order. However, in outpatient therapy (Medicare Part B therapy), adjustment of interventions to achieve an already-established goal does not require a physician’s signature. Compare this to home health (Medicare Part A) where any change to the care plan, including revisions to goals, interventions or visit frequency, must be signed off by the physician.
Having established therapy interventions, charting on them in your treatment note is straightforward. Interventions in general should be defined with enough detail to be useful. Some may have sufficient detail to be included without any corresponding information. More broadly worded interventions should substantiate medical necessity. In our juggling example, further details can include specific exercises attempted, equipment used, number of sets, repetitions, etc. Under outpatient therapy, where your interventions are procedure codes, for instance therapeutic exercises (97110), description of what that actually entailed is certainly called for.
As a rule, you want to capture enough detail to explain what you did, showing that your skills and training were essential to help the patient perform the intervention and that your participation was necessary for the activity. If your intervention is to instruct or train about something, what topics did you cover? You may be additionally documenting patient’s comprehension although if your care plan has an equivalent goal for the patient to achieve a certain level of understanding, then you would instead reflect it as progress toward that goal. If performing exercises or modalities, what equipment was used? What about sets and repetitions? What were the equipment’s settings? You could possibly reflect patient’s response to treatment but remember that anything indicating progress or lack of such should instead be recorded as progress toward the appropriate goals. Keep your documentation of intervention’s specifics to the point since the aim is simply to capture the details of your technique.
Goals, referred to as outcomes at times, are the expected results of your clinical interventions and are categorized as long-term or short-term. Long-term therapy goals can be imagined as a destination and they are required in your care plans. For the juggling example, the long-term goal could be to juggle pins for three minutes without dropping any. In traveling toward that goal, it makes sense to establish landmarks along the way to help ensure that you are traveling in the right direction. These landmarks represent short-term goals. In our example, some short-term goals could be to (1) verbalize/demonstrate the mechanics of juggling with 100% accuracy, (2) improve hand-eye coordination by throwing a tennis ball against a wall and catching it without incident for 3 minutes, and (3) juggle three soft balls without incident for 90 seconds.
It’s vital that established therapy goals relate to the functional impairments identified in the evaluation, are created in collaboration with the patient and that they are measurable. A measurable goal keeps you on track by demonstrating improvement or decline and allowing you to identify treatment plan issues and adjust it appropriately. An example of an ill-defined goal might be “Patient’s fall risk will decrease.” How do you define that decrease? How do you demonstrate progress toward the goal? When do you determine that the goal is met? Compare this with a well-defined and measurable goal such as “Patient will have a decrease in fall risk as demonstrated by improvement on the Tinetti balance score from 8/16 to 12/16 by March 15.”
Like interventions, establishing new therapy goals in most cases requires a physician’s signature on the plan of care or verbal order. Outpatient therapy again provides an exception to the rule because an adjustment to a short-term goal would not need a physician signature if it applies to an unchanged long-term goal. Home health therapists must still obtain a physician signature for any goal change since it would result in a change to the care plan.
After goals are established, how you document on them is important as this provides the majority of the evidence for medical necessity and the clinical appropriateness of treatment. Documentation includes progress made, patient’s response to treatment, and any other factors that affect performance or understanding. Make sure to establish a measurement scale and use it consistently. While functional tests are a great way to assess progress, you may need to utilize metrics that are a little more abstract. For example, when addressing a pediatric feeding issue, if a child goes from not being able to tolerate a certain type of food on the table to tolerating it on his plate, that’s significant and measurable progress.
Documentation on care plan’s goals is your chance to demonstrate your value, so don’t be modest. However, be concise as it’s only the facts that matter and not your wordiness. Briefly and clearly state how the treatment has impacted your patient. Even a temporary set-back offers valuable data as long as you adjust as needed. Likewise if the patient’s performance has remained the same, it still demonstrates measurable data that can be used later to analyze the patient’s progress. While your focus may be on short-term goals during the visit, make sure that you also periodically document (within the long-term goal details) how the short-term goal’s progress impacts the long-term goal. This demonstrates that you are being mindful of the overall progress toward that long-term goal and how it relates to the short-term goal.
Again, concise detail is key. In our juggling example, you might document on the tennis ball short-term goal by stating techniques used and reflecting with the information you provide participant’s improving engagement, increasing speed, fewer drops, less cueing, etc. While your long-term goal documentation may just include number of drops per number of throws applicable to tennis balls.
You can establish interventions and goals in your assessment, or if you aren’t performing one for whatever reason, in a non-visit Plan of Care document. therapyBOSS lets you create customized templates for interventions and goals. Templates naturally help speed up charting and ensure compliance since their language can be carefully crafted. For goals, you’ll be prompted to select either LT (long term) or ST (short term). If the established care plan needs to be updated at some point, therapyBOSS makes it easy with the designated sections for new goals and new interventions. It can even create a physician order automatically if desired. There is also a non-visit Update to Plan of Care document which is very useful if most of the treatment is being done by a therapist assistant.
Because therapyBOSS documentation is care plan driven, documenting on established interventions and goals in the treatment note is simple and intuitive. You’ll know at a glance which interventions and goals have been getting addressed and which haven’t. With just a click, you can see the history from prior visits for each and copy it as you document the selected intervention or goal in the current visit. Additionally, you can designate goals as achieved, optionally commenting if not met completely or there are other details you want to report.
This focus on care plan’s interventions and goals is what makes therapyBOSS treatment documentation almost foolproof with regards to compliance while offering an effective and efficient method for capturing the essentials. It also eliminates extra work that you would have to do otherwise such as facilitating summary reports including 30-day reassessments, progress reports and discharge summaries. therapyBOSS completes these reports almost entirely on its own based on treatment’s documentation of interventions, progress toward goals, goals achieved and functional tests.
therapyBOSS facilitates recording all of the relevant information a typical SOAP note would contain but does so more effectively. There is “Observations” section that can be used to record Subjectiveinformation relevant to your treatment. Objective data is provided via functional tests, which you can document electronically, as well as “Interventions performed”, “Progress toward goals” and “Patient/Caregiver Instructions” sections of the treatment note. Information recorded in “Progress toward goals” and “Goals Achieved” provides opportunities for realizing the appropriateness and efficacy of the care plan while “Plan for Next Visit” gives an opportunity to map out what treatment will be provided on the next visit and possibly what patient/caregiver agreed to work on before next visit.
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