CHAPTER 13

Specialized Documentation

LEARNING OBJECTIVES

After reading this chapter, the reader will be able to:

1. List the key components of a discharge summary.

2. List the essential features of letters to third-party payers to justify need for equipment or equipment purchases.

3. Identify the key features of letters seeking to appeal denials or requesting continuation of services.

4. Discuss the considerations for providing written patient education materials.

Physical therapy documentation can take many different forms. This book has focused on documentation of the initial evaluation, as well as progress notes and treatment notes. However, PTs are involved in many other types of documentation, including discharge summaries, which are completed at the end of an episode of care, and letters to third-party payers. This chapter discusses specific issues related to some of the most common forms of specialized documentation and presents a framework for easy integration of a functional outcomes approach into each form.

DISCHARGE SUMMARIES

At the completion of an episode of care, therapists are required to write a discharge summary. The American Physical Therapy Association Guidelines for Physical Therapy Documentation (2008) state that “documentation is required following conclusion of the current episode in the physical therapy intervention sequence, to summarize progression toward goals and discharge plans.” The main purpose of a discharge summary is to document the status of the patient at the time he or she is discharged. A discharge summary does not require a complete reevaluation. However, therapists should report changes in the patient’s participation, activities, and any limitations or impairments that are pertinent to the stated goals. These can be provided in a summary statement or in a table.

The following are essential components of a discharge summary:

• Patient description. This should include a description of the patient’s diagnosis and background information and can also include description of current plan of care.

• Summary of physical therapy intervention. It should be stated for what length of time and how many sessions the patient received physical therapy services. A brief summary of the interventions that were provided can be provided.

• Current status. Summarize the patient’s current status. This can include any impairments but should focus on the patient’s functional abilities and any participation restrictions as appropriate.

• Goals. It should be indicated whether the goals were achieved, partially achieved, or not achieved. If goals were not achieved or partially achieved, a brief explanation or justification is warranted.

• Recommendations. The PT should list any recommendations for the patient at this point. This plan should include home-based instructions and follow-up or reevaluation instructions. If the patient has moved to another facility (e.g., discharged from acute care to a skilled nursing facility), then any recommendations for continued therapy or other services should be provided.

Figure 13-1 is an example of a discharge summary written in an outpatient hospital setting.

LETTERS TO THIRD-PARTY PAYERS TO JUSTIFY SERVICES OR EQUIPMENT

Letters to third-party payers are frequently written by PTs. These letters are needed to provide justification for either continued services or equipment purchases. When writing such letters, it is important to consider that the reader may not be familiar with all medical terminology, and thus it is essential to avoid medical jargon and abbreviations. The tone should be kept professional, without oversimplication. Therapists should not avoid using medical terminology; however, any uncommon words or terminology should be defined.

EQUIPMENT PURCHASES

Therapists are frequently required to provide justification for the equipment that they plan to provide or wish to obtain for patients. Letters of medical necessity are often required by third-party payers for purchases of expensive medical equipment, such as customized wheelchairs, particularly those purchased through the Medicaid system. The purpose of these letters is to provide medical justification regarding the necessity of the equipment. It is also important to justify the cost. For example, the purchase of a certain piece of equipment now may reduce the need for surgery and/or extended hospital stays in the future. It is also important, whenever possible, to cite examples of research to back up your request.

The following list provides the essential components of a letter of medical necessity:

• Patient description. This should include a description of the patient’s diagnosis and background information and can also include a description of the current plan of care.

• Current status. Summarize the patient’s current status. This can include any impairments but should focus on the patient’s level of participation and performance of activities as appropriate.

• Equipment description. Describe the requested equipment in detail (provide picture or other information if possible). If special components or additions above and beyond standard equipment are required, each item should be separately and explicitly justified.

• Medical necessity of equipment. This is the most important component of the letter. The focus here should be on medical necessity. It should include the medical need for the equipment, specify benefits to the patient, and describe the patient’s ability to use the equipment. It is important, whenever possible, to include evidence from the literature to support the need for the equipment. In addition, the inability of any alternatives (particularly cheaper ones) to meet the patient’s medical needs should be discussed if appropriate. Cost benefits can be explained in detail as well. For example, as seen in Figure 13-2, the use of a stander can help prevent skin breakdown and prevent osteoporosis, which are costly medical conditions.

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