Evaluation
This has to be completed within 36 hours of Patient Admission
The evaluation
This always needs to be completed the same day as treatment
Billing and Charge Capture
This section should be updated weekly with current information and be specific as possible.
Summary
This document needs to be completed/signed within 2 days of Patient Discharge
Discharge Summary
Hand Offs should be updated ...
At time of evaluation, Prior to weekends, exchange days/time off, and/or significant patient updates
These are the commonly found therapy diagnoses in Profile Contribution
muscle weakness, difficulty walking, impaired mobility with ADLs, dysarthria, dysphagia
This needs to be completed if the patient was scheduled, but not seen
Missed Minute Note
True of False? You CAN combine the daily and weekly/progress note into one document.
True
This section should be completed prior to patient discharge because it is printed out and given to the patient at time of discharge
Pt. Instructions
OT dotphrase: .AVSOTREHAB
PT dotphrase: .SCIAVS
When ordering a w/c from an outside vendor, this step needs to be completed to notify the vendor
"New Communication"
This is where you can find the appropriate level of assistance for patient bed and toilet/commode transfers
Mobility Status and Green Mobility Sheet
On a Daily Note, this is where you can confirm Treatment Minutes and Rehab Minutes were completed
"Today's Treatment Time", located at bottom of note
***These are the 3 required sections in a weekly***
- Care Scores
- Short Term Goals
- Summary
What is the difference between "recommendations" versus "plan for continued service after discharge".
Recommendations: what they need to work on
Plan: where they will get their follow up therapy on (OP, HH)
This is how to access a discharged patient's chart
Patient station->enter name/medical ID#->episode (look for ARU admit date and discharge status)
***This is the only component that should be included in the Patient Care Plan***
- Long term goals
OT: .CAREPLANOT
PT: .PTCAREPLAN
When billing for a patient's treatment session, these sections must be completed
Treatment Minutes, Rehab Minutes, Charge Capture
This section does not need to be updated unless new treatment ideas are introduced
Interventions
***This is the process to close out Care Plans when a patient discharges***
Discharge -> Care Plans -> PT/OT/SLP Goals -> Select option of progressing, not progressing, adequate for discharge, or completed
How do you check to make sure Education has been completed at time of evaluation?
Education -> All -> Generic Teaching Goals/Outcomes -> Rehabilitation -> "More" button to see other entries