Eli's Rehab Report
Is Your Daily Documentation Enough? Beware the Treatment Grid
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Question: I work in a SNF and have a question regarding our Med B patients. How often are we expected to document therapy treatments? Do we need daily documentation, or is our daily treatment record enough? We use a daily treatment grid, so is it really necessary to write an actual note every day we see that patient? Delaware Subscriber Answer: The bare-minimum documentation requirements from CMS say you need daily notes, which must include the date, specific interventions and modalities you provided that support the CPT codes you're billing, along with your (the therapist's) signature. In addition, you must document the total time spent providing time-based interventions and total treatment time, which is the summation of timed and untimed interventions. Whether your daily treatment grid is sufficient is hard to determine without actually seeing your grid. You should use more than just a grid for daily notes. It's a good idea for therapists to write the patient's response to treatment after every treatment in addition to any progression/modifications of the treatment plan. Just a grid by itself listing what is done is not the best thing. -- Reader Questions were answered by Rick Gawenda, PT, director of PM&R at Detroit Receiving Hospital and owner of Gawenda Seminars.
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