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Question of the Day |
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Q: What are the documentation requirements for rehabilitation staff for Medicare Part A and Part B residents? For example: physician's orders, plan of care, etc.
A: The consultants in the field recommend that notes be documented in the medical record at least once per 24 hours, describing the condition, status and services provided for the skilled coverage. It is very important that documentation reflect the necessity of daily skilled care services for the beneficiary. Clinical documentation that supports medical necessity may include initial evaluations and therapy notes, progress notes that describe the resident's response and progress to treatments and any other documentation that supports the need for the skilled and rehabilitation service(s). Other documentation can consist of monitoring sheets, attendance logs, consultations, medication and treatment records or plan of care. The number of minutes provided must be documented daily. Physician orders must be present for all residents receiving therapy. There must be an order for the initial evaluation. Physicians must document that they have reviewed the plan of care developed by the therapist and order the outlined service. Services must be reordered at each evaluation and no less often than monthly. The same documentation protocol should be used for both Part A and Part B therapy. If restorative therapy is being provided, the notes should clearly document the reason why therapy is being provided regardless of payment source. Part A and Part B therapy notes should clearly indicate what the resident's prior level of function was. In all situations, therapy and nursing notes must be consistent. |
