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The Patient, the Plan, and the Use of Problem-Based Documentation

Written by: Shawn Hewitt on Friday, July 22, 2016 Posted in: Acute Care Rehab, Inpatient Rehab, Outpatient Rehab, IRF documentation, plan of care

As therapists, one of the most important items of documentation is creating a clear plan of care. To do this, therapists must evaluate and assess each patient to determine “problem areas.” Often, these “problem areas” are caused by impairments that impede patients in completing functional tasks or activities. The documentation of goals should be linked to functional tasks or activities, and the documentation should clearly define what and how the goals will solve the functional problems.

Whether your documentation is paper or electronic, documenting the plan of care in such a way that it clearly supports why services are needed can be challenging. In most professional healthcare services, identification of the diagnosis, a prognosis, and a plan of care are all required. That plan must focus on the problem/goal relationship that is stated in a measurable format and that predicts the level of improvement in regards to impact to overall functional activity. This also calls for a description of status that provides a general statement of interventions that will be used, the planned duration and frequency of service required to solve the patient problem areas and/or meet goals, the anticipated discharge disposition/plan, and of course, patient involvement with setting the plan of care.

Another challenge for therapists is making sure patients’ experience and/or participation is well understood and documented. There is and will be more and more regulatory pressure for therapists to include patient self report on the care and understanding of their conditions as part of the documentation. You may hear terms like “patient engagement,” “patient-centered care,” or “patient-reported outcome measures.” Whether they are requirements or not, including patients in their overall care is the right and responsible thing to do both clinically and financially. The balance therapists must work through with patients is intended to improve their quality of life at the most cost-effective delivery model. To do that, you must include or “engage” the patient. Patients’ understanding of their condition as well as their “self-reported perception” of their ability is critical in therapists’ ability to understand and assess patient functional performance and care.

Here are a few questions every therapist and care provider should be asking:

  • Does your plan of care tell the right story to support why your skilled services are needed?
  • Does documentation use the problem/goal relationship to drive better planning of functional performance improvement?
  • Does your care include each patient’s experience and self-reported status of overall condition/performance?

Top priority should be given to including patients in their plan of care as well as to linking the goals and problems together to ensure effective functional improvement and patient management. Here at Mediware, we work hard to provide tools and workflows that support proper care planning and improving the patient experience.


This Post Has 2 Comments
  1. With respect to therapy coverage by Medicare of pre-clinical lymphedema with no functional deficiency, we may note that Sec. 1862 of the Social Security Act. [42 U.S.C. 1395y] provides that payment may be made under part A or part B for any expenses incurred for items or services which are reasonable and necessary for the diagnosis or treatment of illness or injury. Furthermore, the Medicare Benefit Policy Manual CMS Pub. 100-02, Chapter 15, §220.2 states in part “Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” This is certainly applicable to a progressive condition such as lymphedema, wherein sustained swelling due to lymph stasis (lymphedema) is known to produce inflammation, tissue changes including fat deposition, collagen generation leading to fibrosis, and immune system dysfunction. Therapy services are not limited to rehabilitation.

    To my knowledge there are no activities in progress addressing the situation of measurement of outcomes of disease treatment when there is no disability. If this issue is not addressed, we may soon be in a situation where lymphedema therapists may no longer be reimbursed by Medicare for lymphedema services because they will have no accepted means of documenting effectiveness of therapy until the condition has been allowed to grow to an irreversible and debilitating stage, when treatment is vastly more expensive.

    I believe that we are headed for a disaster for lymphedema therapists and lymphedema patients if we do not modify the current course of action in defining an outcome-related reimbursement policy for therapists. As a discussion starter, I would urge reading of my presentation “Functional outcomes measurement in the absence of disability: the lymphedema example” on my LymphActivist’s Site at

    1. Great comments. All are which legit. I think it is great to encourage folks in this situation to find ways to work and propose policy change. We also encourage participation with AMRPA ( so that these type of issues can be understood and backed with a stronger rehab voice. In the meantime, the importance of proper documentation to explain and link problems and goals to the skilled services we all provide will justify and strengthen our stance.

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