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Arbor Rehabilitation and Healthcare Services, Inc.

Documentation Policies Charting Abbreviations

POLICY TITLE: CHARTING ABBREVIATIONS

APPLICATION: All Rehab Sites

EFFECTIVE DATE: March, 2006

REVISION DATE:

The following list of commonly used abbreviations may be used in the documentation of

patient care. Abbreviations save time, but their excessive use should be discouraged

because of the wide variations in meaning. When ambiguity is likely, terms should be

spelled out to make the documentation more accessible to others.

A

AAROM

ABD

ac

AC>BC

AD

ADD

ADJ

ADM

ADL

AE

AFO

AK

AKA

AM

amb

AMP

Assessment (SOAP note)

Active assisstive range of motion

Abduction

Before meals

Air conduction greater than bone conduction

Right ear (auris dextra)

Adduction

Adjustable

Admission

Activities of daily living

Above elbow

Ankle-foot orthosis

Above knee

Above knee amputation

Morning

Ambulation, ambulate

Amputee






REVISION DATE:

A&O

AROM

AS

AU

Aud

Aud Haluc

audio

B

B>A

bal

B&B

BC>AC

BE

b.i.d

bil

b.i.w.

BK

BKA

BLE

Alert and oriented

Range of motion

Left ear

Both ears (aures unitas)

Auditory

Auditory hallucinations

Audiogram

Both

Bone greater than air

Balance

Bowel and bladder

Bone conduction greater than air conduction

Below elbow

Twice daily

Bilateral

Twice a week

Below knee

Below-knee amputation

Bilateral lower extremities






REVISION DATE:

BP Blood pressure

B.R.

BUE

c

C

Ca

CAD

CAE

cath

CBS

CC

CHD

CHF

CHI

C/o

COPD

COTA

CPM

C.P.T.

Bathroom

Bilateral upper extremities

With

Complaint

Carcinoma

Coronary artery disease

Complete audiometric evaluation

Catheter

Chronic brain syndrome

Chief complaint

Coronary heart disease

Congestive heart failure

Closed head injury

Complains of

Chronic obstructive pulmonary disease

Certified occupational therapy assistant

Continuous passive motion

Chest physical therapy






REVISION DATE:

CVA

d/c

Decr

deg

DF

DI

dias.

DJD

DOB

DOI

DTR

Dx

ed

EENT

elev

end

ENT

Eval

EWHO

Cerebral Vascular Accident

Discharged

Decreased

Degenerative

Dorisflexion

Diabetes insipidus

Diastolic

Degenerative joint disease

Date of birth

Date of injury

Deep tendon reflexes

Diagnosis

Education

Eye, ear, nose, and throat

Elevation

Endurance

Ear, nose, and throat

Evaluation

Elbow wrist hand orthosis






REVISION DATE:

EXT

EXT. ROT.

F

FAM

FL

fl. dr.

fl. oz.

flds

flex

fluoro

F.

FO

Ft.

Func

FWB

Fx

HPB

HEENT

HNP

Extension

External Rotation

female

family

Fluid

Fluid dram

Fluid ounce

Fluids

Flexion

Fluoroscopy

Fairly nourished

Foot orthosis

Foot

Fuction

Full weight-bearing

Fracture

High blood pressure

Head, eyes, ears, nose, and throat

Herniated nucleus pulposus (herniated disk)






REVISION DATE:

HOB Head of Bed

HP Hot Pack

H/O History of

H&P

HR

HVGS

Hx

IDDM

Inc

inf

INJ

Int

I&O

IR

Jt.

LBP

lig

LLE

LOH

LOS

LS

History and Physical

Heart rate

High-voltage galvanic stimulation

History

Insulin-dependent diabetes mellitus

Increased

Inferior

Injury

Internal

Intake and output

Internal rotation

Joint

Low back pain

Ligament

Left lower extremity

Loss of hearing

Length of stay

Lumbosarcal






REVISION DATE:

Lt.

LTM

LUE

M

MAFO

Max

MI

Min

mo

mod

NA

NDT

neg

nl

NPO

N/S

Nsg

NWB

OA

OBS

Left

Long Term Memory

Left upper extremity

Male

Molded ankle-foot orthosis

Maximal

Myocardial infraction

Minimal

Months

Moderate

Not applicable

Neural developmental treatment

Negative

Normal

Nothing by mouth

Normal saline

Nursing

Non-weight bearing

Osteoarthritis

Organic brain syndrome






REVISION DATE:

OOB

OT

O

p

pc

PF

PMH

PNF

PO

po

pos

Prog

PROM

PRN

PSIS

PT

PTB

PVD

q

qd

Out of bed

Occupational Therapy

ref

after

after meals

plantar flexion

past medical history

proprioceptive neuromuscular facilitation

postoperative

by mouth

positive

prognosis

passive range of motion

“as needed basis”

posterosuperior vascular disease

physical therapy

patellar tendon-bearing

peripheral vascular disease

every

every day






REVISION DATE:

QID

QIW

Rehab

ROM

Rx

S

s

SACH

SCI

SI

SLB

SLP

SLR

SNF

SOAP

SOB

ST

Staph

STM

SX

Four times per day

Four times per week

Rehabilitation

Range of motion

Treatment

Subjective (SOAP)

Without

Solid ankle cushion heels

Spinal cord injury

Sacroiliac

Short-leg brace

Speech-language pathology

Straight leg raising

Skilled nursing facility

Subjective, objective, assessment, and plan

Shortness of breath

Speech therapy

Staphylococcus

Short-term memory

Symptoms






REVISION DATE:

SYN

TENS

THA

THR

TIA

tiw

TJ

TKR

TMJ

T.O.

tol

Tx

UE

UNK

US

USI

UTI

UV

VO

VS

Synergy

transcutaneous electrical nerve stimulation

total hip arthroplasty

total hip replacement

transient ischemic attack

three times a week

triceps jerk (reflex)

total knee replacement

temporal mandibular joint

telephone order

tolerated

treatment

upper extremity

unknown

ultrasound

urinary stress incontinence

urinary tract infection

ultraviolet

verbal order

vital signs






REVISION DATE:

WB

WC

WFL

wk

WN

WNL

w/o

WP

wt

YO

Yr

Weight-bearing

Wheelchair

Within functional limits

Week

Well-nourished

Within normal limits

Without

Whirlpool

Weight

Years old

year


Documentation Policies Clarification Orders Page 1

POLICY TITLE: CLARIFICATION ORDERS



REVISION DATE: December, 2014

POLICY

Clarification orders will be obtained on all residents prior to initiating treatment.

PURPOSE

To provide a formal review of the specific treatment plan prior to initiating treatment

services and ensure physician authorization of planned treatments.

PROCESS

1. Clarification orders are obtained either by writing the order out on a telephone

order slip or using facility based electronic medical record system, per facility

directives.

2. Telephone orders completion- be sure to include the following:

A. Type of service: PT, OT, SLP

B. Frequency- Be specific in frequency per week.

Example: 3 times per week not 3-5 times per week

C. Duration- Be specific in the duration of the plan of treatment.

Example: 4 weeks not 4-6 weeks

D. Procedures/Modalities

E. Date, name and discipline of therapist writing the order

3. A new clarification treatment order is required to be written when there is change

in the Plan of Treatment. For example: change in frequency; adding or deleting a

modality/procedure. The new clarification order will include the complete plan of

treatment.

4. Therapy discharge orders may be required as well per facility directives.


Documentation Policies Documentation Page 1

POLICY TITLE: DOCUMENTATION


EFFECTIVE DATE: October, 2010


POLICY

Documentation will be completed in a timely manner.

PURPOSE

To ensure adherence to professional standards, promote team communication, and comply with

payor mandates.

PROCESS

All documentation and related billing will be completed at the time of service delivery.

Evaluation and re-certification forms are to be completed with ensuing physician orders on the

day they are billed.

Daily notes are due each day before leaving the building; tenth visit progress reports are due upon

each tenth therapy date.

Discharge documentation is due at the time of patient discharge from therapy.

All documentation is to be completed according to the standards per the Rehab Optima

documentation system and per Arbor Rehabilitation’s documentation training webinars.


Documentation Policies Evaluations Page 1

POLICY TITLE: EVALUATIONS




POLICY

Upon receipt of physician’s order, evaluations will be completed.

PURPOSE

The evaluation provides information for the establishment of the plan of treatment,

interdisciplinary communication, MDS completion, care planning, reimbursement,

accreditation and regularly requirements.

PROCESS

1. All disciplines will complete the appropriate sections of the discipline specific

evaluation form.

2. Objective Data: Complete the areas that are assessed and document the specific

and objective clinical data gathered at the time of the initial evaluation. Identify

objective measurement tools used to gather data. Areas not tested should be

marked N/A if area will not be addressed on the POC. If the area is to be

addressed on the POC it should be noted as “Unable” or “Totally Dependent”.

3. Patient/ caregiver goals should reflect the actual goals specified or stated by the

resident, family or caregiver. Example: “I want to walk again”, “I want to be able

to play golf”, and “I want to eat real food”.

4. All fields indicated in Red on the Rehab Optima must be completed. Descriptors

may be found by hovering the cursor over each section.

5. Electronic signatures are required upon completion of the evaluation.

6. All procedures or modalities rendered must be indicated on the Plan of Treatment.

7. All POCs must have at least one long and one short term goal. Goals are not to be

repeated.

8. Physician signature is required on OT, PT, ST Plans of Care.


Documentation Policies Interdisciplinary Screen Page 1

POLICY TITLE: INTERDISCIPLINARY HISTORICAL SCREEN



REVISION DATE: December 8, 2010

POLICY

It is the policy of Arbor Rehabilitation and Healthcare Services Inc. to screen all residents for

possible therapy intervention. These screenings may be completed upon admission/readmission,

upon facility referral, upon resident change in functional status or according to a quarterly/annual

schedule.

PURPOSE

The purpose of the therapy screen is to ensure that all residents have the opportunity to receive

therapy services if a functional decline has occurred and skilled services are indicated. Screening

policy compliance will support compliance with OBRA regulations for promotion of optimal

levels of function.

PROCESS

1. All screens will consist of a brief review of the medical record, interview of the

resident/staff/family and observation of the resident in the environment. NO hands-on

intervention is performed. No direct recommendations are made based on the screen with

the exception of whether or not a therapy evaluation is indicated. Completion of the

screening form occurs after the above tasks. (see instructions for form completion)

2. The screening is/may be performed by one discipline which includes the chart review,

resident observation and or interview/staff interview and completion of the form. It is

expected that this process will be done in 48 business hours for new admissions

/readmissions, facility referred residents, residents for whom a change in status has been

noted.

3. Annual/quarterly screens need to be completed two weeks prior to the Assessment

Reference Date per the RNAC.

a. The MDS schedule should be provided to the FRC mid month for the scheduled

quarterly and annual assessments due the following month.

b. Residents on schedule will be reviewed during the routine Medicare meeting

regarding the results of the screen, plan to evaluate and interdisciplinary team

input regarding the resident’s need for therapy. If a resident has shown a decline,

nursing documentation should support this change. Completed screens may be

brought to the meeting for review.

c. Residents receiving part B services will be discussed at the routine Medicare

meeting. During this meeting the FRC needs to ensure that the RNAC has a rehab

score for each resident on therapy that quarter. If the resident does not have a

rehab score, the facility and rehab should agree upon an appropriate ARD.


Documentation Policies Interdisciplinary Screen Page 2

4. FRC attendance at daily nursing meetings may also trigger the need for a therapy screen.

As the FRC is made aware of falls, new physician orders, and changes in status such as

confusion, difficulty in transfers/ambulation/ADL’s, hygiene, positioning and oral intake,

a screen should occur. In this way a resident’s status may be informally monitored daily.

5. A therapists’ observation of any resident may also trigger the need for a screen if a change

in status is noted.

6. The therapy department will maintain the screening form in a specially marked binder

that is available to appropriate facility staff during business hours. A copy of all discharge

summaries should be included in this screening binder in order to better highlight

potential changes in patient status.

7. All screens will be completed according to state regulations for each therapy discipline.

All disciplines and licensees are able to perform therapy screens. Screening forms should

be co-signed if an assistant has completed the screen.

8. Please see the Instructions for the Completion of the Interdisciplinary Historical

Screen/Data Collection Form for further information regarding screening process

completion.

Attachments:

Interdisciplinary Historical Screen Form

Interdisciplinary Historical Screen Form Instructions

Interdisciplinary Historical Screen/Data Collection Facility:

Name:____________________________ Rm.________ Significant PMH:__________________________________________

Status Areas Date: Date: Date: Date:

Reason For

Screen

Relevant order

change

Prior Level Mobility Change yes/no Change yes/no Change yes/no Change yes/no

Wheelchair mobility

Ambulation

Falls

Balance

ADL’s Change yes/no Change yes/no Change yes/no Change yes/no

Grooming

Dressing

Toileting/Continence

Self feeding/ equip

Effective adapt equip

Positioning/Skin Change yes/no Change yes/no Change yes/no Change yes/no

Wound

Bed, W/C position

Effective equipment

Pain/Contractures Change yes/no Change yes/no Change yes/no Change yes/no

UE ROM

LE ROM

Contractures/Splint

Pain complaints

Swallowing Change yes/no Change yes/no Change yes/no Change yes/no

Intake method/amt.

Diet

Coughing/drooling

Weight change

Communication Change yes/no Change yes/no Change yes/no Change yes/no

Alert/Oriented

Safety/ Behaviors

Signature:

Co Signature:

Please circle as

appropriate

Refer to

PT/OT/ST/None Refer to



PT/OT/ST/None

Date/Comments:_____________________________________________________________________

Date/Comments:_____________________________________________________________________

Date/Comments:_____________________________________________________________________

Date/Comments:_____________________________________________________________________

Instructions for the Completion of the

Interdisciplinary Historical Screen/Data Collection Form

1. Therapist initiating this form completes the top section for the

patient’s name, room number and therapy relevant medical history.

2. Under the date, the reason for the screen should be noted for

clarification, (IE: a fall or quarterly screen).

3. Any relevant physician order changes should be noted in this

section to further support the screen and possible referral (IE: diet

texture changes).

4. As a therapist initiates the screening, he or she should look back at

any previous therapy discharge summaries for long term care

residents and enter that information in the column titled “Prior

level” and the date. If a resident is new to the facility, or only on

for a brief episode of rehab. or was not previously on therapy, this

section may be filled out with the notation “Per pt. report” or “Per

facility report” It is essential that this section reflects the

resident’s highest level of functioning in the recent past. For

example: A resident that was independent in the community 1

month ago, went to the hospital and admitted to rehab at a max

assist level, returned to the hospital and now readmitted at a max

assist level would be best described as “Independent in the

community one month ago” This prior status must reflect the

person’s highest recent functional level to support the need for

skilled therapy if indicated per the results of the screen. One

therapist may complete this historical data for all discipline areas.

5. For each subsequent column, the date the screening occurs must

be completed along with a yes/no notation if there is an

observed/reported change in any of the functional/safety areas

listed.

6. The screening form must be signed/co-signed each time a column

is completed.

7. The therapist completing the form must circle the appropriate

discipline for a referral or circle “None” if no evaluations are

indicated. Please note that a screening should be brief. If

questions/concerns require an extended amount of time (IE: more

than 10-15 minutes) a referral for an evaluation should be made to

the appropriate discipline. Remember there is no hands-on contact

during a screen.

8. Lines at the bottom of the page may be used for additional

comments or to clarify the reason for a referral.

9. .This form is to be placed in a binder in the department. A copy or

the original may need to be placed in the chart per facility policy.


Documentation Policies Medical Record Corrections Page 1

POLICY TITLE: CORRECTING THE MEDICAL RECORD




POLICY

All therapists will comply with accepted practice for medical record entries and deletions.

This includes all paper and electronic entries.

PURPOSE

To maintain the integrity of medical records.

PROCESS

1. The medical record is a legal document. Accuracy of all entries is a requirement

of regulatory, accreditation and reimbursement authorities. If the medical record

needs to be altered, the correction must be done appropriately; otherwise the

accuracy of the entire record will be called into question. This would be

disastrous in any court or legal proceeding, affecting both the professional

administering care and the patient/resident him/herself.

2. Correcting One’s Own Error In The Medical Record: If a mistake is made while

making an entry, a single line should be drawn through the error followed by the

date and signature or initials of the individual making the correction. Never

scribble over, erase, or use white-out on an entry. When more space is needed,

make the new entry as close as possible to the original error as an addendum. The

addendum is dated and signed and must refer to the location of the record being

corrected.

3. For those therapists who can write orders in the medical record and need to make

a correction, draw a single line through the error followed by the date, time and

signature or initials of the individual making the correction, then have the nurse

countersign the order immediately.

4. If the error is not found while making the entry, the correction is made as a late

entry addendum. The original document is not altered at this time. The

addendum must refer back in time to the erroneous entry and is dated, timed, and

signed at the exact time it is written. Never backdate an entry!


Documentation Policies Medical Record Corrections Page 2

5. Correcting Another Person’s Error In The Medical Record: If it is discovered an

error has been made by another person, inform that person immediately so the

correction can be made.

6. Prohibited Medical Record Entries and Deletions Include:

a. Use of white-out

b. Use of erasers

c. Use of pencils

d. Back dating or entering a date or time that is other than the actual date and

time the entry is made.

e. Making a medical record entry for someone and signing the same for the

other person

f. Rewriting a portion of or an entire medical record


Documentation Policies Medical Record Organization Page 1

POLICY TITLE: ORGANIZATION OF THE REHABILITATION SECTION

OF THE MEDICAL RECORD




POLICY

The rehabilitation section of a patient’s medical record must be maintained in an orderly

manner that is consistent with sound medical record keeping practice. If facility specific

medical record procedures indicate a format for maintaining the rehabilitation section,

those procedures must be followed. However, if procedures are not specified, the

following organization is to be followed for those facilities with paper based hard charts.

PURPOSE

To maintain proper organization of the rehabilitation section of the medical record.

PROCESS

1. As approved by the facility Administration, the rehabilitation section must be

subdivided with separate discipline specific sections. If tabs are not available, an

alternate divider such as colored sheets should be used to divide documents by

discipline.

2. Within each section, the order must be chronologically built by certification

period with the most current documentation on top. Original certifications/

recertifications and printed out electronic documents are to be maintained in the

patient’s hard chart per facility policy.

3. The respective certification periods are maintained as follows from bottom to top:

(certification period 1) Plan of Treatment, Progress Notes, Daily treatment

encounter notes, (certification period 2) Updated Plan of Progress, Progress Notes,

Daily treatment encounter notes, and so on.

4. Physician orders for rehabilitation services must be clearly delineated in the

medical record.


Documentation Policies Medical Record Page 1

POLICY TITLE: THE MEDICAL RECORD




POLICY

It is the policy of Arbor Rehabilitation that each therapist will maintain clinical records

on all patients/residents that reflect the current professional standards and practices and

complies with the facility’s policies and procedures.

PURPOSE

To provide a medical record, which is an accurate record of service delivery, maintain

confidentiality and to meet established state or federal guidelines for record keeping.

PROCESS

1. Medical Records Storage

a. All records (including documents that have not been filed in the

medical record) kept in the rehab department will be maintained under

lock and key overnight or when not in use, providing access to

qualified personnel only.

b. The medical record (paper or electronic versions) should be monitored

at all times to protect the confidential nature of the information

included in the record. This includes keeping the medical record

closed, out of plain view from the unqualified personnel.

c. The original medical record will not be removed from the facility for

any reason.

2. Medical Record Documentation and Use

a. The medical record is the property of the facility. The staff will follow

written guidelines/policies of the facility regarding medical record use

and release of information.

b. All documentation will be filed in the medical record immediately after

completion or per facility guidelines such as upon discharge from therapy.

c. Corrections are to be made per the correction policy.


Documentation Policies Medical Record Page 2

f. Soft files containing signed certifications/ recetifications will be

maintained in the department or designated location for a period of no

less than 2 years.

g. The medical record will contain at the minimum, an evaluation with

the original signed certification, all original signed re-certifications,

progress reports, service log and discharge summary. Other

documents may be included per facility request.


Documentation Policies Multidisciplinary Therapy Screen Page 1

POLICY TITLE: MULTIDISCIPLINARY THERAPY SCREEN


EFFECTIVE DATE: May 1, 2006

REVISION DATE:

POLICY

In the absence of evaluation orders for all disciplines, patients may be screened by therapy

staff upon admission and readmission. Long term care and assisted living residents may

be screened quarterly with physician orders; upon facility request and/or physician request

based on a documented change in status. If necessary and appropriate, state regulations

will take precedence.

PURPOSE

To provide the patient and/or resident with the opportunity to receive therapy services if

functional declines are present; skilled services are required; and to ensure compliance

with OBRA regulations for maintenance of optimal levels of function.

PROCESS

1. All screens will consist of a brief review of the medical record; interview of

patient/resident, staff, family; observation of patient/resident in environment. No

“hands on” formal testing is completed. No direct recommendations are made

based on information obtained from a screen with the exception that further

evaluation is indicated.

2. When to perform a Multidisciplinary Therapy Screen:

Admission/Readmission: All patients are screened within 48 hours of

admission/readmission to the facility.

Referrals from Physician/Nursing: These patients are screened by the specific

discipline to which the referral was made.

Quarterly with Physician Order: These patients are screened by one therapy

discipline to determine the need for OT, PT, and/or ST.

3. All screens are to be completed in accordance with specific State rules and

regulations.

4. The Multidisciplinary Therapy Screen will be completed according to the

Instructions for Completing the Multidisciplinary Therapy Screen.


Documentation Policies Physician Order/Telephone Orders Page 1

POLICY TITLE: PHYSICIAN ORDERS AND TELEPHONE ORDERS



REVISION DATE: April, 2006

POLICY

It is the policy of Arbor Rehabilitation that prior to rendering therapy services to any

resident there must be a written physician’s order on the medical record.

PURPOSE

Written physician orders are required for insurance and Medicare reimbursement and

state practice acts require written orders prior to initiating evaluation and treatment.

PROCESS

A. Prior to initiating the evaluation the therapist will review the physician order

section of the medical record looking for the specific initial order to evaluate the

resident.

B. The initial order must specify the discipline and procedure to occur. Example:

“ST to evaluate” is sufficient to initiate ST services with an evaluation only.

“Swallow study” is not sufficient enough to initiate treatment because it does not

indicate who will do the swallow study.

C. The order must be signed and dated by the physician in accordance with the

facility’s policy.

D. Telephone Orders:

1. Can be taken by a therapist in most states, check with the supervisor

regarding the policy for the facility.

2. The initial telephone order is typically used for Plan of Treatment

development and therefore assistants do not take telephone orders.

3. Develop a system for calling the physician. Avoid numerous calls. Check

with facility Director of Nursing regarding their policy. They may already

have a system in place.

4. Keep all calls brief and to the point. Have the telephone order written prior to

calling so that it can be read and signed off on at the time the call is made.

5. Identify a system for getting the orders noted by nursing. How will the

nursing staff know the order is there? Some facilities use an inbox for

orders and others have a system where new orders are flagged in the

medical record.

E. If the facility has computer generated orders, determine the system for getting

orders generated by the computer as required by the facility.


Documentation Policies Plans of Treatment - Changes Page 1

POLICY TITLE: CHANGES IN PLAN OF TREATMENT AND

RE-CERTIFICATION



REVISION DATE: April, 2006

POLICY

1. If a therapist wants to change the Plan of Treatment, the telephone order

procedures must be followed.

2. For Medicare Part A and Part B residents, the physician must re-certify any

changes to the Plan of Treatment. AND,

3. The Plan of Treatment must be re-certified every 30 days or less.

PURPOSE

1. Written physician orders are required for insurance and Medicare reimbursement.

Therefore any changes to the Plan of Treatment would need to be documented by

the physician in order to comply with Medicare regulations.

2. Medicare requires re-certification of the Plan of Treatment. Therefore, the

recertification of the plan of treatment would need to be documented and signed

by the physician in order to comply with Medicare regulations.

PROCESS

1. Follow the procedure established at the facility for changes to the Plan of

Treatment. The following process is recommended:

a. The therapist will try to contact the physician for a verbal telephone order

to initiate the new treatment.

b. If the physician is unable to be reached, the Plan of Treatment or telephone

order will be faxed or mailed to the appropriate physician.

2. For Medicare only. Follow the procedure established at the facility for re-

certification. The following process is recommended:

a. Complete the Plan of Treatment form; check off 30-day re-certification.

b. Make a copy of the completed Plan of Treatment form.

c. Fax or mail the plan care form to the physician.

d. Take the copy of the completed form and write faxed or mailed and the

date in the physician’s signature space.

e. File the copy of the form in the physician’s order section of the medical

record until the signed copy is returned. When the signed copy is received,

replace the copy with the signed one in the medical record.

f. Keep a log of faxes sent or mailed to track responses.


Documentation Policies Wound Care Documentation Page 1

POLICY TITLE: DOCUMENTATION OF WOUND CARE



REVISION DATE: June, 2006

POLICY

All Physical therapists will complete required documentation for wound care prior to the end of

the working day of the provision of service at each facility. Documentation will meet all

Medicare and Medicaid requirements.

PURPOSE

Arbor provides practice guidelines for the accurate and appropriate documentation of wound care

service provided by Physical Therapy.

PROCESS

1. Evaluation:

a. The evaluation is completed within 24 hours of receipt of order.

b. Utilize the Arbor Rehab. Physical Therapy Wound Evaluation form.

c. Complete the form in its entirety.

d. Us the clinical reasoning process to determine the reasons for Physical Therapy

involvement, keeping in mind the Medicare reimbursable guidelines.

2. Wound Care Orders:

a. The Physical Therapy orders will include:

i. Date

ii. Physical Therapy

iii. Frequency, intensity (BID, QD) and duration of treatment

iv. Location of the wound

v. Treatment modalities/procedures and dressing specifications

vi. Physician signature

b. In the event that nursing and physical therapy are both providing wound care, a separate

order for each discipline indicated each responsibility should exist.


Documentation Policies Wound Care Documentation Page 2

3. Goals:

The long term and short term goals should be established using the following criteria:

a. Patient specific

b. Measurable, percentages, stages, centimeters, etc.

c. Realistic and achievable

d. Functional

4. Daily Note:

a. A daily entry is completed using the Arbor Rehab. Services wound treatment and

progress note form.

b. One form is used per wound being treated.

c. If nursing is also treating, both disciplines may document on the same form.

d. A narrative note is made on a progress note page if there is a significant issue, problem

or change that requires supporting documentation.

e. Documentation will include the skilled intervention that was required for the patient to

achieve their goals; a summary of the functional benefits as a result of skilled

intervention; specific measurements of pain, stages, level, percentages, etc., and the

recommendations for continued treatment or discontinuation of treatment.

arbor rehabilitation and healthcare services, inc. · herniated nucleus pulposus (herniated disk)...

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