Given stringent guidelines for what must be documented in an outpatient plan of care is essential to gain efficiency in documentation. This is particularly true when completing the evaluation of a given patient that is seeking your care for a very specific purpose. I’ve seen extremely long documentation practices, that somehow lose even the therapist that created the plan, because hidden in all the information is distracting unimportant facts and figures.
A good plan of care will immediately detail what “ails” the patient and results in a lower than optimal functional status that significantly impacts their premorbid status. A reliable measure of function should be taken with the expected results given a specific timeline and treatment regime. Following guidelines provided in the Medicare Manual (Chapter 1, Section 15; 220 -230), a checklist for components that must be present is written. Follow that checklist – keeping as tightly aligned as possible.
Demonstrate the skill sets required by your profession to educate, train and impact the measurement that provides success and you have a winning formula that is very efficient. All too often I read notes that can’t sustain the original argument for why the care is needed. Unfortunately, payers and auditors find the same smoke and mirrors; generally not intentional – just same ‘ol, same ‘ol. We already have guidelines that limit visit numbers, treatment types and specific modalities. These guidelines and Local Medical Review Policies (LMRP’s) came about because as a profession, we forgot to focus.
Focus on what’s important and what gets that individual back in the “saddle” so to speak. KISS does it. No one has time to waste and time and money are getting tighter!