![]() ![]() PT educated patient in B hand strengthening exercises post estim to improve overall grip/pincer grasps. ![]() Patient reported “it feels looser.” Patient verbalized 3/10 pain post session indicating positive results from directed exercises.Ħ. OT individualized and instructed patient in AROM exercises to max patient range in pain free zone as follows: IR/ER, abd/add 1×10, extension with 3 second hold. Patient instructed in the following exercises to increase RUE ROM, decrease stiffness and reduce pain level: pulleys 1-2 minutes x 3 trials to increase shoulder flexion with short rest in between trials. R shoulder ROM measurements taken as follows: OT assessed and measured R shoulder flexion: 60 degrees, ABD: 58 degrees, EXT: 20 degrees, IR: 20 degrees, ER: 25 degrees. Patient arrived at skilled OT complaining of 5/10 R shoulder pain limiting UE dressing tasks. Able to mimic after visual demo with good execution.ĥ. Patient also instructed in pursed lipped breathing to reduce complaints of shortness of breath and elicit usage of energy conservation techniques. O2 > 96% when monitored during rest breaks, RR 22 post exercise, 18 at baseline. PT utilized Modified Borg Scale and patient reported 2/10 during exercise. PT directed patient x 18 minutes requiring 2 therapeutic rest breaks due to complaints of fatigue and increased respiration. Patient instructed in BLE recumbent bike training to increase overall functional activity tolerance and LE strength to maximize balance and reduction of falls during mobility. Patient denied shortness of breath and indicated just right challenge.Ĥ. O2 monitored pre, during and post exercise with O2 levels > 95% to ensure positive response and reduce risk of desaturation. Patient required verbal cues for erect posture to maximize cardiopulmonary function. Patient completed x 15 minutes with PT facilitating interval training of varying resistance 1-2 minutes. Patient directed in NuStep training to increase biofeedback to BLE, mimic reciprocal pattern and increase overall BLE strength to decrease abnormal gait pattern. Patient reporting exercises are helping him “not drag my foot as often.”ģ. Increased time needed to execute and allow for therapeutic rest. PT facilitated patient to complete standing ther ex including heel raises with BUE support, using mirror for visual feedback to ensure proper form, 2×15. Required max verbal cues, tactile cues and visual demo to reduce compensatory strategies. trained in ankle dorsiflexion, plantar flexion, inversion/eversion with 3 second hold. Patient required min verbal cues and visual demo to initiate each exercise using 2# ankle weights for B knee flex/ext. In seated position, patient was instructed in LLE strengthening exercises to decrease left foot drop during ambulation prior to functional mobility task. Patient was able to execute with no reported increase in pain in prep for gait training.Ģ. Increase of 5 degrees in L hip abduction was achieved through exercises since last reporting period. Min A provided due to LE weakness and prevention of substitution movements. In side lying, patient instructed in 3×10 L hip abduction, L hip extension with verbal cues to isolate targeted muscle groups and initiate appropriate exercise. Patient instructed in L hip exercises to increase L hip ROM/strength for improved balance and overall pain reduction. Patient arrived at therapy with 3/10 L hip pain. (Skilled terminology is highlighted in red.)ġ. To help therapists and assistants improve their documentation, the following are examples of documentation that clearly demonstrates the skilled nature of therapeutic exercise. Auditors often rely on repetitive or otherwise poor documentation to deny a claim based on the conclusion that therapeutic exercise did not require the skills of a therapist.Ī therapist’s skills may be documented by descriptions of skilled treatment, changes made to treatment due to an assessment of the patient’s needs on a particular treatment day or changes due to progress the therapist judged sufficient to modify treatment toward the next more complex or difficult task. Services that do not require the performance or supervision of a therapist are not considered “skilled” even if they are performed by a therapist. The two most important PT/OT documentation requirements are demonstrating that care is (1) medically necessary and (2) skilled.Ĭare is regarded as “skilled” only if it is at a level of complexity and sophistication that requires the services of a therapist or an assistant supervised by a therapist.
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