RE: frequency of progress reports for hospital acute care PT

[Guest guest]

We enter a note for each visit. It is an important

communication for the physician, social services and

nursing. Also assures continuity of care. The notes

are brief. If an insurance company audits the record,

the notes correspond with the charges. Our average

length of stay is only 4 days, so weekly or every 5

days would not be very useful.

Pat Cornwell

Palos Community Hospital'

Palos Heights, Illinois

--- White wrote:

> Hi,

>

> I'm looking for references for standards on the

> necessary frequency of progress reports for PT for

> hospital inpt acute care. Our current policy is

> every 5th visit or once a week, but am unable to

> find what this was based on originally. Any help

> would be most appreciated.

>

> thanks

>

>

>

>

> Becky White, PT, CCS

> Supervisor and Cardiovascular Clinical Specialist

> Acute Care Team

> University of Michigan Hospitals

> Ann Arbor, MI

>

> Electronic Mail is not secure, may not be read every

> day, and should not be used for urgent or sensitive

> issues.

>

>

>

>

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

> Electronic Mail is not secure, may not be read every

> day, and should not be used for urgent or sensitive

> issues.

>

Pat Cornwell

Dir. of Rehab Services

Palos Community Hospital

Palos Heights, Illinois

__________________________________________________

[Guest guest]

We do daily notes as well, my question was regarding a " progress note " that

addresses progress toward each goal, adjustment of short term goals and plan.

We have typically been doing these every 5th visit or once a week and I'm trying

to find a reference for the need for progress notes in acute care and their

frequency, outpatient has fairly specific requirements for frequency of these at

every 10th treatment day or 30 days, whichever is first from medicare.

becky

>>> Cornwell 4/20/2007 9:14 AM >>>

We enter a note for each visit. It is an important

communication for the physician, social services and

nursing. Also assures continuity of care. The notes

are brief. If an insurance company audits the record,

the notes correspond with the charges. Our average

length of stay is only 4 days, so weekly or every 5

days would not be very useful.

Pat Cornwell

Palos Community Hospital'

Palos Heights, Illinois

--- White wrote:

> Hi,

>

> I'm looking for references for standards on the

> necessary frequency of progress reports for PT for

> hospital inpt acute care. Our current policy is

> every 5th visit or once a week, but am unable to

> find what this was based on originally. Any help

> would be most appreciated.

>

> thanks

>

>

>

>

> Becky White, PT, CCS

> Supervisor and Cardiovascular Clinical Specialist

> Acute Care Team

> University of Michigan Hospitals

> Ann Arbor, MI

>

> Electronic Mail is not secure, may not be read every

> day, and should not be used for urgent or sensitive

> issues.

>

>

>

>

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

> Electronic Mail is not secure, may not be read every

> day, and should not be used for urgent or sensitive

> issues.

>

Pat Cornwell

Dir. of Rehab Services

Palos Community Hospital

Palos Heights, Illinois

__________________________________________________

[Guest guest]

We use a flow sheet with that information that is

filled out on the initial visit and updated/revised as

needed. To my knowledge there is no specific

requirement. In my 36 years of practice, I do not

recall any JCAHO requirement and we have never had a

problem with reviews. (of course, I will now keep my

fingers crossed)

Pat Cornwell

--- White wrote:

> We do daily notes as well, my question was regarding

> a " progress note " that addresses progress toward

> each goal, adjustment of short term goals and plan.

> We have typically been doing these every 5th visit

> or once a week and I'm trying to find a reference

> for the need for progress notes in acute care and

> their frequency, outpatient has fairly specific

> requirements for frequency of these at every 10th

> treatment day or 30 days, whichever is first from

> medicare.

>

> becky

>

> >>> Cornwell

> 4/20/2007 9:14 AM >>>

> We enter a note for each visit. It is an important

> communication for the physician, social services and

> nursing. Also assures continuity of care. The notes

> are brief. If an insurance company audits the

> record,

> the notes correspond with the charges. Our average

> length of stay is only 4 days, so weekly or every 5

> days would not be very useful.

> Pat Cornwell

> Palos Community Hospital'

> Palos Heights, Illinois

> --- White wrote:

>

> > Hi,

> >

> > I'm looking for references for standards on the

> > necessary frequency of progress reports for PT for

> > hospital inpt acute care. Our current policy is

> > every 5th visit or once a week, but am unable to

> > find what this was based on originally. Any help

> > would be most appreciated.

> >

> > thanks

> >

> >

> >

> >

> > Becky White, PT, CCS

> > Supervisor and Cardiovascular Clinical Specialist

> > Acute Care Team

> > University of Michigan Hospitals

> > Ann Arbor, MI

> >

> > Electronic Mail is not secure, may not be read

> every

> > day, and should not be used for urgent or

> sensitive

> > issues.

> >

> >

> >

> >

>

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

> > Electronic Mail is not secure, may not be read

> every

> > day, and should not be used for urgent or

> sensitive

> > issues.

> >

>

>

> Pat Cornwell

> Dir. of Rehab Services

> Palos Community Hospital

> Palos Heights, Illinois

>

>

> __________________________________________________

>

[Guest guest]

You may not actually find any specific details for an inpatient acute care

setting. That's what the most recent Medicare Transmittal was about and they

rescinded it. (65). CMS was actually looking to provide guidelines for

inpatient settings by taking the OP requirements and adapting them. What we

have done here (we're a large academic based hospital) is build all of those

components into our electronic documentation so we are constantly reviewing /

updating our plan of care each time we write a note. If you give it some

thought, you can make it concise and streamlined, even if you are still on

paper.

Good luck!!

Pat Nellis

-Jewish Hospital

St. Louis, MO

" White " 4/20/07 9:44 AM >>>

We do daily notes as well, my question was regarding a " progress note " that

addresses progress toward each goal, adjustment of short term goals and plan.

We have typically been doing these every 5th visit or once a week and I'm trying

to find a reference for the need for progress notes in acute care and their

frequency, outpatient has fairly specific requirements for frequency of these at

every 10th treatment day or 30 days, whichever is first from medicare.

becky

Nellis, MBA, OT/L

Manager, Rehabilitation Department

-Jewish Hospital

St. Louis, MO 63110

Office:

Pager:

Fax:

>>> Cornwell 4/20/2007 9:14 AM >>>

We enter a note for each visit. It is an important

communication for the physician, social services and

nursing. Also assures continuity of care. The notes

are brief. If an insurance company audits the record,

the notes correspond with the charges. Our average

length of stay is only 4 days, so weekly or every 5

days would not be very useful.

Pat Cornwell

Palos Community Hospital'

Palos Heights, Illinois

--- White wrote:

> Hi,

>

> I'm looking for references for standards on the

> necessary frequency of progress reports for PT for

> hospital inpt acute care. Our current policy is

> every 5th visit or once a week, but am unable to

> find what this was based on originally. Any help

> would be most appreciated.

>

> thanks

>

>

>

>

> Becky White, PT, CCS

> Supervisor and Cardiovascular Clinical Specialist

> Acute Care Team

> University of Michigan Hospitals

> Ann Arbor, MI

>

> Electronic Mail is not secure, may not be read every

> day, and should not be used for urgent or sensitive

> issues.

>

>

>

>

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

> Electronic Mail is not secure, may not be read every

> day, and should not be used for urgent or sensitive

> issues.

>

Pat Cornwell

Dir. of Rehab Services

Palos Community Hospital

Palos Heights, Illinois

__________________________________________________

[Guest guest]

We do daily treatment notes, continually reassessing progress toward goals, and

write a progress report to formally re-evaluate progress once per week.

However, if the goal time frame was less, we will do a progress report earlier.

So, basically, we go by what the original POC stated.

Hope this helps!

Jill Piazza, PT, MSPT

Florida Hospital DeLand

Re: frequency of progress reports for hospital acute care

PT

To: PTManager

> We enter a note for each visit. It is an important

> communication for the physician, social services and

> nursing. Also assures continuity of care. The notes

> are brief. If an insurance company audits the record,

> the notes correspond with the charges. Our average

> length of stay is only 4 days, so weekly or every 5

> days would not be very useful.

> Pat Cornwell

> Palos Community Hospital'

> Palos Heights, Illinois

> --- White wrote:

>

> > Hi,

> >

> > I'm looking for references for standards on the

> > necessary frequency of progress reports for PT for

> > hospital inpt acute care. Our current policy is

> > every 5th visit or once a week, but am unable to

> > find what this was based on originally. Any help

> > would be most appreciated.

> >

> > thanks

> >

> >

> >

> >

> > Becky White, PT, CCS

> > Supervisor and Cardiovascular Clinical Specialist

> > Acute Care Team

> > University of Michigan Hospitals

> > Ann Arbor, MI

> >

> > Electronic Mail is not secure, may not be read every

> > day, and should not be used for urgent or sensitive

> > issues.

> >

> >

> >

> >

> **********************************************************

> > Electronic Mail is not secure, may not be read every

> > day, and should not be used for urgent or sensitive

> > issues.

> >

>

>

> Pat Cornwell

> Dir. of Rehab Services

> Palos Community Hospital

> Palos Heights, Illinois

>

>

> __________________________________________________

>

[Guest guest]

We write progress notes for each visit. This includes the patient's

progress, functional status and response to treatment. We have had

Medicare FI audits on inpatient charts that looked carefully for

documentation of each visit that was billed. And in 2 instances they

denied claims where they could not find documentation by PT when there

was a charge submitted for a particular date. (The denials were for

substantial parts of the billed claims. Yes I know that payment for

Medicare inpatient sis DRG based but we received denials anyway.)

Our inpatient charts the are fully integrated with all disciplines

writing in the same progress note section.

L. Gessner, PT

Chief Physical Therapist

South Nassau Communities Hospital

Ocenaside, NY

>

> You may not actually find any specific details for an inpatient acute

care setting. That's what the most recent Medicare Transmittal was

about and they rescinded it. (65). CMS was actually looking to

provide guidelines for inpatient settings by taking the OP requirements

and adapting them. What we have done here (we're a large academic

based hospital) is build all of those components into our electronic

documentation so we are constantly reviewing / updating our plan of

care each time we write a note. If you give it some thought, you can

make it concise and streamlined, even if you are still on paper.

>

> Good luck!!

>

> Pat Nellis

> -Jewish Hospital

> St. Louis, MO

[Guest guest]

A year ago we rebuilt our (daily) documentation screens in Meditech.

These new screens are intentionally pretty exhaustive - the idea being

that when fully documented on, every daily note has all the info

normally contained in a progress or d/c note. Screens are set up

w/certain functionality features that allow recall of repeating info day

to day, and also allow goals to be revised/update/upgraded during

documentation. Has worked well in our acute care setting.

Leonard Paladino, PT

Coordinator of Rehabilitation Services

Delnor-Community Hospital

Geneva, IL 60134

leonard.paladino@...

________________________________

From: PTManager [mailto:PTManager ] On

Behalf Of Cornwell

Sent: Friday, April 20, 2007 8:14 AM

To: PTManager

Subject: Re: frequency of progress reports for hospital

acute care PT

We enter a note for each visit. It is an important

communication for the physician, social services and

nursing. Also assures continuity of care. The notes

are brief. If an insurance company audits the record,

the notes correspond with the charges. Our average

length of stay is only 4 days, so weekly or every 5

days would not be very useful.

Pat Cornwell

Palos Community Hospital'

Palos Heights, Illinois

--- White <rebwhite@...

<mailto:rebwhite%40med.umich.edu> > wrote:

> Hi,

>

> I'm looking for references for standards on the

> necessary frequency of progress reports for PT for

> hospital inpt acute care. Our current policy is

> every 5th visit or once a week, but am unable to

> find what this was based on originally. Any help

> would be most appreciated.

>

> thanks

>

>

>

>

> Becky White, PT, CCS

> Supervisor and Cardiovascular Clinical Specialist

> Acute Care Team

> University of Michigan Hospitals

> Ann Arbor, MI

>

> Electronic Mail is not secure, may not be read every

> day, and should not be used for urgent or sensitive

> issues.

>

>

>

>

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

> Electronic Mail is not secure, may not be read every

> day, and should not be used for urgent or sensitive

> issues.

>

Pat Cornwell

Dir. of Rehab Services

Palos Community Hospital

Palos Heights, Illinois

__________________________________________________

[Guest guest]

Leonard,

Your documentation tools sound similar to what we did with Cerner last

year. It is very comprehensive, to the point that staff complain that

it is taking them longer to document now than before when they were

doing hand written notes. They each have tuffbooks that they carry with

them, but they find it virtually impossible to document during or

immediately after seeing the patient. They still tend to do them at the

end of the morning, over lunch, and at the end of the day. Are you

finding that it is taking your staff longer to document? Anything stand

out in your mind that you were able to change to make the computerized

format more efficient?

Carol Rehder, PT

Manager, Physical Therapy

Genesis Medical Center

rehder@genesis@...

>>> leonard.paladino@... 4/23/2007 1:33 PM >>>

A year ago we rebuilt our (daily) documentation screens in Meditech.

These new screens are intentionally pretty exhaustive - the idea being

that when fully documented on, every daily note has all the info

normally contained in a progress or d/c note. Screens are set up

w/certain functionality features that allow recall of repeating info

day

to day, and also allow goals to be revised/update/upgraded during

documentation. Has worked well in our acute care setting.

Leonard Paladino, PT

Coordinator of Rehabilitation Services

Delnor-Community Hospital

Geneva, IL 60134

leonard.paladino@...

________________________________

From: PTManager [mailto:PTManager ] On

Behalf Of Cornwell

Sent: Friday, April 20, 2007 8:14 AM

To: PTManager

Subject: Re: frequency of progress reports for hospital

acute care PT

We enter a note for each visit. It is an important

communication for the physician, social services and

nursing. Also assures continuity of care. The notes

are brief. If an insurance company audits the record,

the notes correspond with the charges. Our average

length of stay is only 4 days, so weekly or every 5

days would not be very useful.

Pat Cornwell

Palos Community Hospital'

Palos Heights, Illinois

--- White <rebwhite@...

<mailto:rebwhite%40med.umich.edu> > wrote:

> Hi,

>

> I'm looking for references for standards on the

> necessary frequency of progress reports for PT for

> hospital inpt acute care. Our current policy is

> every 5th visit or once a week, but am unable to

> find what this was based on originally. Any help

> would be most appreciated.

>

> thanks

>

>

>

>

> Becky White, PT, CCS

> Supervisor and Cardiovascular Clinical Specialist

> Acute Care Team

> University of Michigan Hospitals

> Ann Arbor, MI

>

> Electronic Mail is not secure, may not be read every

> day, and should not be used for urgent or sensitive

> issues.

>

>

>

>

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

> Electronic Mail is not secure, may not be read every

> day, and should not be used for urgent or sensitive

> issues.

>

Pat Cornwell

Dir. of Rehab Services

Palos Community Hospital

Palos Heights, Illinois

__________________________________________________