By Wendy Bircher PT EdD
How very important is documentation? Very! actual Therapist Assistants needs to supply the correct documentation to guarantee all varieties of compensation (including 3rd celebration) for his or her providers. And, applicable documentation additionally addresses problems with sufferer confidentiality, HIPAA necessities, and the ever-increasing calls for of felony and moral perform in a litigious society. construct your scholars documentation abilities and their self belief, step-by-step, with the tips and perform they ll locate within the third variation. They ll be ready to meet the technological demanding situations of today...and day after today.
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Extra info for Lukan's Documentation for Physical Therapist Assistants
THROUGH DC SERVICES 02Bircher(F)-02 8/10/07 3:33 PM Page 27 CHAPTER 2 ■ Documentation Content DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES UPDATED PLAN OF PROGRESS FOR OUTPATIENT REHABILITATION (Complete for Interim to Discharge Claims. ) 1. PATIENT’S LAST NAME FIRST NAME 4. PROVIDER NAME 5. MEDICAL RECORD NO. (Optional) 8. I. 2. PROVIDER NO. 3. HICN 6. ONSET DATE 7. SOC. DATE 9. TREATMENT DIAGNOSIS 11. VISITS FROM SOC. PT OT SLP CR RT PS SN SW 12. , 3/Wk. ) 13.
DATE 9. TREATMENT DIAGNOSIS 11. VISITS FROM SOC. PT OT SLP CR RT PS SN SW 12. , 3/Wk. ) 13. ) GOALS (Short Term) PLAN OUTCOME (Long Term) I HAVE REVIEWED THIS PLAN OF TREATMENT AND RECERTIFY A CONTINUING NEED FOR SERVICES. 14. RECERTIFICATION N/A DC FROM 15. PHYSICIAN’S SIGNATURE 16. DATE THROUGH N/A 17. ON FILE (Print/type physician’s name) 18. ) 19. SIGNATURE (or name of professional, including prof. designation) 20. DATE 21. CONTINUE SERVICES OR DC SERVICES 22. ) 22. SERVICE DATES FROM Form CMS-701(11-91) Figure 2—11 Medicare Recertification Form CMS-701.
Informed Consent to the Treatment Plan All aspects of the treatment plan, including the purposes, procedures, expected results, and any possible risks or side effects of treatment, must be explained to the patient and signiﬁcant others. In some cases, the patient may participate in designing the plan. The patient or a representative for the patient should agree to the treatment plan and procedures. His or her 02Bircher(F)-02 34 8/10/07 3:33 PM Page 34 PART ONE ■ Why is Documentation Important? Box 2–4 Physical Therapy versus Medical Diagnosis Physical Therapy Diagnosis Ataxia of lower extremities with inability to ambulate independently.
Lukan's Documentation for Physical Therapist Assistants by Wendy Bircher PT EdD