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Discharge Summaries

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Good morning,

Does anyone know if there are CMS guidelines as to whether a PTA or COTA can

write the discharge summary? I thought there was a federal rule on this but

I've only been able to find state specific therapy boards with mention in

their rules and regs.

What if an assistant writes it but the therapist cosigns?

Thanks for any insight you can provide!

Angelique Kim

The Weston Group

Ext 43

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Its stated under Medicare Benefit Policy Pub 100-02, Transmittal 36

The services of PTAs used when providing covered therapy benefits are

included as part

of the covered service. These services are billed by the supervising

physical therapist.

PTAs may not provide evaluation services, make clinical judgments or

decisions or take

responsibility for the service. They act at the direction and under the

supervision of the

treating physical therapist and in accordance with state laws.

This if from APTA

DIRECTION AND SUPERVISION OF THE PHYSICAL THERAPIST ASSISTANT HOD

P06-05-18-26 (Program 32)

Regardless of the setting in which the service is provided, the following

responsibilities must be borne solely by the physical therapist:

1. Interpretation of referrals when available.

2. Initial examination, evaluation, diagnosis, and prognosis.

3. Development or modification of a plan of care which is based on the

initial examination or reexamination and which includes the physical therapy

goals and outcomes.

4. Determination of when the expertise and decision-making capability of

the physical therapist requires the physical therapist to personally render

physical therapy interventions and when it may be appropriate to utilize the

physical therapist assistant. A physical therapist shall determine the most

appropriate utilization of the physical therapist assistant that provides

for the delivery of service that is safe, effective, and efficient.

5. Reexamination of the patient/client in light of their goals, and

revision of the plan of care when indicated.

6. Establishment of the discharge plan and documentation of discharge

summary/status.

7. Oversight of all documentation for services rendered to each

patient/client.

Discharge planning and documenting discharge summary is the sole

responsibility of the primary therapist who analyzes, interpret data for

making appropriate recommendations for a safe discharge.

There's no cms guidelines that the primary therapist needs to cosign notes,

it depends on the state practice acts and local laws. Here in new jersey

the physical therapist assistant: 13:39A-2.3 Authorized role of a licensed

physical therapist assistant

(a) A licensed physical therapist assistant may initiate physical therapy

treatment only at the direction of and under the direct supervision of a

licensed physical therapist. A licensed physical therapist assistant shall

not initiate physical therapy treatment upon the direction of a physician or

other authorized health care provider without the direct supervision of a

physical therapist.

(B)-© (No change.)

(d) A licensed physical therapist assistant shall not perform a physical

therapy examination, evaluation, diagnosis or prognosis, develop a plan of

care, modify a plan of care, or independently engage in physical therapy

instruction, including, but not limited to, the recommendation of assistive

devices and modifications of the patient's physical environment.

The primary therapist needs to co-sign all documentations made by the PTA

because of direct supervision.

Hope this helps.

Cruz, PT, GCS

Clinical Rehabilitation Manager

Bristol Glen CCRC, United Methodist Homes

New Jersey

_____

From: PTManager [mailto:PTManager ] On Behalf

Of TWGSE

Sent: Thursday, November 02, 2006 7:17 AM

To: ptmanager

Subject: Discharge Summaries

Good morning,

Does anyone know if there are CMS guidelines as to whether a PTA or COTA can

write the discharge summary? I thought there was a federal rule on this but

I've only been able to find state specific therapy boards with mention in

their rules and regs.

What if an assistant writes it but the therapist cosigns?

Thanks for any insight you can provide!

Angelique Kim

The Weston Group

Ext 43

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  • 4 months later...
Guest guest

Taken from Advance online edition:

Vol. 17 *Issue 25 * Page 50

Medicare Advisor

Rules for Discharge Summaries in Acute Care

By ine M. o, MCSP, PT, and Danna D. Mullins, MHS, PT

Question: When reading a previous Medicare Advisor column, I was

relieved to understand that in the acute hospital setting, a formal

discharge summary is not necessary.........................

Is the above true: Discharge summaries are not necessary in the acute

hospital setting?

Thank-you,

Carol

Carol Sangi PT, MHA

Director, Quality / Therapy Services

or

Quality fax number: (201)858-7363

Therapy Services fax number: (201)858-7620

e-mail: csangi@...

**********************************************************************

This email and any files transmitted with it are confidential and

intended solely for the use of the individual or entity to whom they

are addressed. If you have received this email in error please notify

the system manager.

This footnote also confirms that this email message has been swept by

MIMEsweeper for the presence of computer viruses.

www.clearswift.com

**********************************************************************

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Guest guest

Taken from Advance online edition:

Vol. 17 *Issue 25 * Page 50

Medicare Advisor

Rules for Discharge Summaries in Acute Care

By ine M. o, MCSP, PT, and Danna D. Mullins, MHS, PT

Question: When reading a previous Medicare Advisor column, I was

relieved to understand that in the acute hospital setting, a formal

discharge summary is not necessary.........................

Is the above true: Discharge summaries are not necessary in the acute

hospital setting?

Thank-you,

Carol

Carol Sangi PT, MHA

Director, Quality / Therapy Services

or

Quality fax number: (201)858-7363

Therapy Services fax number: (201)858-7620

e-mail: csangi@...

**********************************************************************

This email and any files transmitted with it are confidential and

intended solely for the use of the individual or entity to whom they

are addressed. If you have received this email in error please notify

the system manager.

This footnote also confirms that this email message has been swept by

MIMEsweeper for the presence of computer viruses.

www.clearswift.com

**********************************************************************

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Guest guest

Taken from Advance online edition:

Vol. 17 *Issue 25 * Page 50

Medicare Advisor

Rules for Discharge Summaries in Acute Care

By ine M. o, MCSP, PT, and Danna D. Mullins, MHS, PT

Question: When reading a previous Medicare Advisor column, I was

relieved to understand that in the acute hospital setting, a formal

discharge summary is not necessary.........................

Is the above true: Discharge summaries are not necessary in the acute

hospital setting?

Thank-you,

Carol

Carol Sangi PT, MHA

Director, Quality / Therapy Services

or

Quality fax number: (201)858-7363

Therapy Services fax number: (201)858-7620

e-mail: csangi@...

**********************************************************************

This email and any files transmitted with it are confidential and

intended solely for the use of the individual or entity to whom they

are addressed. If you have received this email in error please notify

the system manager.

This footnote also confirms that this email message has been swept by

MIMEsweeper for the presence of computer viruses.

www.clearswift.com

**********************************************************************

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Guest guest

Taken from Advance online edition:

Vol. 17 *Issue 25 * Page 50

Medicare Advisor

Rules for Discharge Summaries in Acute Care

By ine M. o, MCSP, PT, and Danna D. Mullins, MHS, PT

Question: When reading a previous Medicare Advisor column, I was

relieved to understand that in the acute hospital setting, a formal

discharge summary is not necessary.........................

Is the above true: Discharge summaries are not necessary in the acute

hospital setting?

Thank-you,

Carol

Carol Sangi PT, MHA

Director, Quality / Therapy Services

or

Quality fax number: (201)858-7363

Therapy Services fax number: (201)858-7620

e-mail: csangi@...

**********************************************************************

This email and any files transmitted with it are confidential and

intended solely for the use of the individual or entity to whom they

are addressed. If you have received this email in error please notify

the system manager.

This footnote also confirms that this email message has been swept by

MIMEsweeper for the presence of computer viruses.

www.clearswift.com

**********************************************************************

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Guest guest

Taken from Advance online edition:

Vol. 17 *Issue 25 * Page 50

Medicare Advisor

Rules for Discharge Summaries in Acute Care

By ine M. o, MCSP, PT, and Danna D. Mullins, MHS, PT

Question: When reading a previous Medicare Advisor column, I was

relieved to understand that in the acute hospital setting, a formal

discharge summary is not necessary.........................

Is the above true: Discharge summaries are not necessary in the acute

hospital setting?

Thank-you,

Carol

Carol Sangi PT, MHA

Director, Quality / Therapy Services

or

Quality fax number: (201)858-7363

Therapy Services fax number: (201)858-7620

e-mail: csangi@...

**********************************************************************

This email and any files transmitted with it are confidential and

intended solely for the use of the individual or entity to whom they

are addressed. If you have received this email in error please notify

the system manager.

This footnote also confirms that this email message has been swept by

MIMEsweeper for the presence of computer viruses.

www.clearswift.com

**********************************************************************

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Guest guest

Taken from Advance online edition:

Vol. 17 *Issue 25 * Page 50

Medicare Advisor

Rules for Discharge Summaries in Acute Care

By ine M. o, MCSP, PT, and Danna D. Mullins, MHS, PT

Question: When reading a previous Medicare Advisor column, I was

relieved to understand that in the acute hospital setting, a formal

discharge summary is not necessary.........................

Is the above true: Discharge summaries are not necessary in the acute

hospital setting?

Thank-you,

Carol

Carol Sangi PT, MHA

Director, Quality / Therapy Services

or

Quality fax number: (201)858-7363

Therapy Services fax number: (201)858-7620

e-mail: csangi@...

**********************************************************************

This email and any files transmitted with it are confidential and

intended solely for the use of the individual or entity to whom they

are addressed. If you have received this email in error please notify

the system manager.

This footnote also confirms that this email message has been swept by

MIMEsweeper for the presence of computer viruses.

www.clearswift.com

**********************************************************************

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Guest guest

Taken from Advance online edition:

Vol. 17 *Issue 25 * Page 50

Medicare Advisor

Rules for Discharge Summaries in Acute Care

By ine M. o, MCSP, PT, and Danna D. Mullins, MHS, PT

Question: When reading a previous Medicare Advisor column, I was

relieved to understand that in the acute hospital setting, a formal

discharge summary is not necessary.........................

Is the above true: Discharge summaries are not necessary in the acute

hospital setting?

Thank-you,

Carol

Carol Sangi PT, MHA

Director, Quality / Therapy Services

or

Quality fax number: (201)858-7363

Therapy Services fax number: (201)858-7620

e-mail: csangi@...

**********************************************************************

This email and any files transmitted with it are confidential and

intended solely for the use of the individual or entity to whom they

are addressed. If you have received this email in error please notify

the system manager.

This footnote also confirms that this email message has been swept by

MIMEsweeper for the presence of computer viruses.

www.clearswift.com

**********************************************************************

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Guest guest

Taken from Advance online edition:

Vol. 17 *Issue 25 * Page 50

Medicare Advisor

Rules for Discharge Summaries in Acute Care

By ine M. o, MCSP, PT, and Danna D. Mullins, MHS, PT

Question: When reading a previous Medicare Advisor column, I was

relieved to understand that in the acute hospital setting, a formal

discharge summary is not necessary.........................

Is the above true: Discharge summaries are not necessary in the acute

hospital setting?

Thank-you,

Carol

Carol Sangi PT, MHA

Director, Quality / Therapy Services

or

Quality fax number: (201)858-7363

Therapy Services fax number: (201)858-7620

e-mail: csangi@...

**********************************************************************

This email and any files transmitted with it are confidential and

intended solely for the use of the individual or entity to whom they

are addressed. If you have received this email in error please notify

the system manager.

This footnote also confirms that this email message has been swept by

MIMEsweeper for the presence of computer viruses.

www.clearswift.com

**********************************************************************

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Share on other sites

Guest guest

Taken from Advance online edition:

Vol. 17 *Issue 25 * Page 50

Medicare Advisor

Rules for Discharge Summaries in Acute Care

By ine M. o, MCSP, PT, and Danna D. Mullins, MHS, PT

Question: When reading a previous Medicare Advisor column, I was

relieved to understand that in the acute hospital setting, a formal

discharge summary is not necessary.........................

Is the above true: Discharge summaries are not necessary in the acute

hospital setting?

Thank-you,

Carol

Carol Sangi PT, MHA

Director, Quality / Therapy Services

or

Quality fax number: (201)858-7363

Therapy Services fax number: (201)858-7620

e-mail: csangi@...

**********************************************************************

This email and any files transmitted with it are confidential and

intended solely for the use of the individual or entity to whom they

are addressed. If you have received this email in error please notify

the system manager.

This footnote also confirms that this email message has been swept by

MIMEsweeper for the presence of computer viruses.

www.clearswift.com

**********************************************************************

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Guest guest

Hi Carol,

In our setting, we only complete a discharge summary if we discharge a

pt from caseload but they are staying in the hospital. Otherwise, if

a patient who is on caseload is discharged from the hospital our last

treatment note serves as their " latest " functional stats/discharge

note.

Jill Piazza, PT

RE: discharge summaries

To: PTManager

> Taken from Advance online edition:

> Vol. 17 *Issue 25 * Page 50

> Medicare Advisor

> Rules for Discharge Summaries in Acute Care

> By ine M. o, MCSP, PT, and Danna D. Mullins, MHS, PT

> Question: When reading a previous Medicare Advisor column, I was

> relieved to understand that in the acute hospital setting, a formal

> discharge summary is not necessary.........................

> Is the above true: Discharge summaries are not necessary in the acute

> hospital setting?

>

> Thank-you,

> Carol

>

> Carol Sangi PT, MHA

> Director, Quality / Therapy Services

> or

> Quality fax number: (201)858-7363

> Therapy Services fax number: (201)858-7620

> e-mail: csangi@...

>

>

>

>

>

>

**********************************************************************

> This email and any files transmitted with it are confidential and

> intended solely for the use of the individual or entity to whom they

> are addressed. If you have received this email in error please notify

> the system manager.

>

> This footnote also confirms that this email message has been swept by

> MIMEsweeper for the presence of computer viruses.

>

> www.clearswift.com

>

**********************************************************************

>

>

>

>

>

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Guest guest

Carol,

In CA, Title 22 states that discharge summaries are needed in all settings.

We do them within 7 days of discharge. Can't remember where the reference of 7

days came from. A few years back, during one of our hospital surveys, DHS asked

specifically for the discharge summaries for a list of acute care patients so I

am sure it is still required by at least DHS standards.

Marie M. Chan MPT

Glendale, CA

" Sangi, Carol " wrote:

Taken from Advance online edition:

Vol. 17 *Issue 25 * Page 50

Medicare Advisor

Rules for Discharge Summaries in Acute Care

By ine M. o, MCSP, PT, and Danna D. Mullins, MHS, PT

Question: When reading a previous Medicare Advisor column, I was

relieved to understand that in the acute hospital setting, a formal

discharge summary is not necessary.........................

Is the above true: Discharge summaries are not necessary in the acute

hospital setting?

Thank-you,

Carol

Carol Sangi PT, MHA

Director, Quality / Therapy Services

or

Quality fax number: (201)858-7363

Therapy Services fax number: (201)858-7620

e-mail: csangi@...

**********************************************************************

This email and any files transmitted with it are confidential and

intended solely for the use of the individual or entity to whom they

are addressed. If you have received this email in error please notify

the system manager.

This footnote also confirms that this email message has been swept by

MIMEsweeper for the presence of computer viruses.

www.clearswift.com

**********************************************************************

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