Tips and tools for rehab professionals: Initial evaluation documentation

Rehab Regs, April 3, 2009

The initial examination is usually your first encounter with your patients, and the resulting evaluation creates a foundation for future therapy treatments. During initial evaluations, determine whether patients meet reasonable and necessary criteria for skilled therapy services. If they do not meet these criteria, it is your professional obligation to inform them that skilled therapy services are not required. Remember that the evaluation can be billed even if you don’t recommend therapy because it is needed to determine whether skilled services are necessary.

When determining whether patients meet reasonable and necessary criteria, you must do the following, regardless of the payer:

  • Conduct a thorough, subjective history of illness or injury, including date of onset, past medical and surgical history, medications, prior and current functional status, home living situation, and goals of therapy
  • Perform a thorough, objective examination, documenting baseline results
  • Develop a list of problems based on the results of the subjective intake and objective examination
  • Determine functional deficits from the examination results
  • Establish short- and long-term goals with expected time frames for achievement
  • Develop a plan of care in conjunction with the patient and his or her physician to meet those goals

This tip is from HCPro’s book The How-To Manual for Rehab Documentation, by Rick Gawenda, PT.

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