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Dire Need of Documentation Tips
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Dire Need of Documentation Tips - February 6, 2001 6:05:00 AM
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nursejackie
Posts: 4
Joined: February 5, 2001
From: Scottsboro AL USA
Status: offline
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Our physical therapy department is trying to invent a treatment form to be used for our patients. Is there anyone out there willing to share the form their facility uses so I can get some ideas. We have found that our documentation is greatly lacking in substance, and I feel like certain things need addressed. Shouldn't you indicate how many "units" of a particular modality you performed?? Also, when documenting, currently our facility will document "therapeutic exercises", but will charge for "therapeutic activities, strength and endurance, and therapeutic charges", but in my opinion their initial entry of "ther. ex" does not back up the multiple charges. I would really appreciate your input into this matter......
Jackie Cibulka, RN, BSN
Medical Management Coordinator
Jackson County Hospital
(256) 218-3737
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Re: Dire Need of Documentation Tips - February 6, 2001 3:20:00 PM
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nursejackie
Posts: 4
Joined: February 5, 2001
From: Scottsboro AL USA
Status: offline
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First of all, thank you for your quick response to my "cry for help". I am employed as an auditor at a hospital, so I am referring to both inpatient and oupatient physical/occupational therapy that is performed at our hospital.
I liked the link you forwarded to me...looks like it covers a lot of information.
I look forward to talking to you again, um, "Bird".
Thanks!!
nursejackie@hotmail.com
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Re: Dire Need of Documentation Tips - February 13, 2001 6:24:00 AM
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Ron
Posts: 105
Joined: January 8, 2001
Status: offline
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Get a copy of the January issue of the PT journal. It has a lot of information on the "hows and whys" of PT practice. Also information from HCFA will give you the guidelines on proper documantation.
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