Home Health Maintenance Therapy Documentation

September 12, 2014

The biggest mistake in home health care is our treatment of maintenance therapy as a separate and incomprehensible monster distinct from traditional rehabilitative therapy treatment. The truth is, there is little mystique when it comes to the home health maintenance therapy documentation. At its core, the same rules apply. Is it reasonable? Is it necessary? Does it require the skills of a qualified therapist? Your answer to all three questions better be “yes” and your documentation needs to support it. Always remember the cardinal rule of providing clinical services: IF YOU DIDN’T DOCUMENT IT, YOU DIDN’T DO IT. This bears repeating because it is the number one clinician error I continue to see in my over fifteen years in home health care – If you did not document that you performed it, evaluated it, taught it, treated it, observed it, discussed it, etc., there is no evidencethat you did it.

So what does this mean? It starts with a thorough evaluation and plan of care. Yes, even a maintenance therapy case should have a plan of care that is developed with the patient and appropriate caregivers and is approved and signed off by the patient’s physician and updated at least every 60 days. The plan of care should reflect the patient’s history, diagnoses, prior level of function, current assessment of level of function utilizing standardized, industry-accepted tests and measurements, appropriate interventions developed by the skilled therapist that in his/her experience have the best chance of improving/maintaining the patient’s level of function, appropriate frequency and duration of services, realistic, appropriate goals that will demonstrate the effectiveness of the interventions and anticipated discharge plans.

Contrary to what some people may believe the development of the plan of care starts with the patient – not with the clinical diagnosis. Traditional clinical pathways may be utilized as a jumping-off point but many factors contribute to the patient’s condition and should be considered and documented as well. The patient’s support system can influence the amount and level of treatment. If a patient lives alone, they may require many more therapy visits than a patient who has teachable and involved family and friends to help in their treatment. A patient’s mental status or education level may affect their ability to understand and perform home exercise programs safely and effectively. Other factors such as whether the patient uses an assistive device, how long the patient has been living with the illness/injury, and the probably of prolonged impairment, among others also effect the plan of care and should be documented. The clinical judgment of the qualified therapist is required to make these decisions and factors that influence that judgment must always be recorded in documentation.

So now that you have established a plan of care, each treatment visit must be documented by a progress note. The progress note must include evidence of the skilled services provided in that visit. If no skilled services are provided in the visit, the visit is considered non-skilled and therefore non-billable. The progress note must also include the date and time of treatment, signature and professional credentials of the person performing the visit, evidence that the skilled services provided required the knowledge and experience of the therapist providing the service, response to treatment/progress toward goals with documentation of changes in the plan of treatment when necessary, and discharge planning. The documentation of the visit should alwaysdemonstrate that the treatment provided required the skilled services of the therapist and could not have been safely and effectively accomplished by the patient, family, caregiver or unskilled personnel. Most importantly, each progress note should be able to stand on its own and demonstrate the need for skilled services independently of any other progress note or evaluation. therapyBOSS is a valuable tool in ensuring that complete documentation occurs with every note.

And don’t forget those therapy reassessments. If you’re the only therapist in and the patient is on a maintenance program, it is likely that you will only need to be concerned with the 30-day assessment (there will probably be considerably less than 13 visits in the episode). However, you will still need to perform and document the 30-day reassessments at least every 30 days. This 30-day count is regardless of what episode you are in, so you need to be sure that you are counting visit intervals between episodes as well. Remember, reassessment visits can only be performed by a qualified therapist and must quantifiably justify continued therapy services using industry-accepted, standardized and validated tests. And if you’re not the only therapist in the case, you’ll need to coordinate with the other therapists involved to ensure that you’re not missing those all-important 13th and 19th visit reassessments as well. Did you know that therapyBOSS will track your visits and alert you when it is time to do a reassessment visit? therapyBOSS also helps you complete the reassessment documentation quickly and effortlessly.

So, you’ve survived all of the documentation hurdles and pitfalls and it is finally time to discharge the patient. Your documentation needs to be solid on this piece as well as you summarize the care provided during the entire period of care. It is important to emphasize the effect that you, the skilled therapist, had on the patient and their progress toward goals or explanation of lack of progress if applicable. Toot your horn a bit as you clinically explain how your interventions improved your patient’s outcomes (or at least halted an anticipated decline in function). Explain those environmental or social factors that contributed to the length of time it took to reach your goals. Let therapyBOSS summarize your care interventions that you have documented throughout the continuum of care.

You know you’re an excellent therapist. Your therapy company and home health agencies you work with know you’re an excellent therapist as well. Make sure your documentation always reflects the awesome work you do. It all goes back to that cardinal rule: IF YOU DIDN’T DOCUMENT IT, YOU DIDN’T DO IT. So do it, let therapyBOSS help you document it, and watch those phone calls from agencies go away as your documentation speaks for itself.