We're So Smart and So Skilled! Do You Make That Evident in Your Documentation?
Section: Section on Health Policy & Administration
Session Code: HP-2B-3916
Date: Friday, January 25, 2019
Time: 11:00 AM - 1:00 PM
Location: Walter E. Washington Convention Center
Room: 158AB

Speaker(s):   Donna Diedrich, PT, DPT, Board-Certified Clinical Specialist in Geriatric Physical Therapy
  Jaclyn K Warshauer, PT

Session Type: Educational Sessions
Session Level: Intermediate

We're smart! We're skilled! But that's not often what comes through in our documentation. Why is that? As we become experienced therapists analyzing our patients during treatment, making subtle adjustments to obtain a more desired response becomes second nature. Do we lose sight of the extensive education and treatment experience it takes to acquire these skills? Our expertise is defined by analysis of impairments and movement or cognitive patterns that are less than optimal and limit function. Integrating evidenced-based practice and clinical reasoning into an effective and efficient person-centered plan of care requires knowledge, experience, and skill.Payers scrutinize our skills because our documentation does not accurately reflect our services. Could this be due to the paradox of expertise쳌? Do we overlook our skill and fail to effectively document how our expertise leads to patient outcomes? We are the value“not the equipment or the number of visits. The payer wants to know that they are paying for a service that only you, a licensed, highly educated and trained therapist, can provide. Learning to effectively and concisely document your skill in relation to patient outcomes demonstrates the value you provide and can reduce the risk for denials. This session will review the importance of effectively documenting your skill, which is necessary for communication, safe patient hand-off, and reimbursement.

Learning Objectives: Upon completion of this course, you will be able to:

1. Explain what a medical reviewer expects to see documented for skilled services related to physical therapy.

2. Identify key terminology for documenting and detailing your skill for services provided.

3. Describe strategies to more effectively support skilled physical therapy, evidenced by your knowledge, analysis, and treatment through your progress reports and daily notes.

CEU: 0.2

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