Home Health & Hospice

Insider's Scoop | Completion of assessment

Homecare Insider, January 18, 2016

Editor’s Note: This week’s Insider’s Scoop is from The Post-Acute Care Guide to Maintenance Therapy. Medicare coverage for maintenance therapy in the post-acute world has been unclear, causing improper documentation and reimbursement. In this guide, authors Cindy Krafft, PT, MS, and Diana L. Kornetti, PT, MA, provide crucial regulatory information and analysis as well as hands-on, practical advice for care and documentation. The guide also features tools, sample forms, and worksheets that allow for easy comprehension of information. Click here for more information.

Assessment components of the patient referred for therapy in inpatient rehabilitation facilities, home health, skilled nursing facility, or outpatient therapy setting remain constant. They are determined by a combination of the patient’s presentation and the defined skill set of the qualified therapist (physical therapist, occupational therapist, or speech-language pathologist).

The initial assessment is the time point where decision-making occurs about whether the patient will receive therapy, as well as the type of therapy. Regardless of the documentation system used, or the reason for referral of the patient for therapy service, your skill set as a therapist and the areas that you evaluate remain constant. Based on the presentation of the patient at the time of initial assessment, both the impairments that you measure (e.g., cognition, strength, balance, swallow, communication, mobility) and the functional
limitations experienced by the patient will vary. Thorough completion of an initial assessment demands that the therapist complete a system-by-system review.

To paint a complete picture, the therapist cannot focus only on the reason the patient was referred to therapy but must include other conditions, comorbidities, and factors that have the potential to impact care.