The Link Between Nursing Documentation and Therapy Services

I am sure every nurse has heard, “If you didn’t document it, it didn’t happen.” As nurses, we have had the importance of documentation drilled in our heads from the first semester of nursing school, and rightfully so! So much depends on our notes.

According to the American Nurses Association (ANA) there are five reasons for appropriate and accurate documentation including, 

• Promotes safe patient care
• Promotes communication and collaboration among healthcare disciplines
• Validates the need for services
• Affords timely reimbursements for facilities
• Legal requirement

Documentation can be a very broad topic though. Every area of patient care requires an accurate and thorough assessment.  Not only do we paint a picture of our patient, but we also validate other services our patient is in need of too.

So, what about therapy services such as physical therapy, occupational therapy, and speech therapy? 

Why is it important for nursing documentation to support therapy?

Nursing notes are essential to support or back up therapy services being provided to the patient. Why? It all comes down to two things….the money and the patient’s needs!

Any facility reimbursed by the Center for Medicare and Medicaid Services (CMS) has specific assessments and documentation that must be submitted substantiating the need for services rendered before payment is disbursed.

Below are just a couple examples of the assessments submitted by each facility for reimbursement of services:

• Skilled Nursing Facility (SNF) – Minimum Data Set (MDS) assessment
• Home Health Agency (HHA) – Outcome and Assessment Information Set (OASIS)
• Inpatient Rehabilitation Facility (IRF) – Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI)

These assessments are very lengthy and require validation for the services rendered by all disciplines. This documentation must correlate across healthcare disciplines.

>> Related: What is an MDS Nurse?

What are some facilities where it matters?

There are many different settings where nursing documentation is crucial for reimbursement of therapy services.

A few of these areas include:

• Skilled nursing facilities (SNF)
• Swing bed
• Home health – when both skilled nursing and therapy are provided
• Inpatient rehabilitation facilities
• Long-term acute care facility (LTAC)

How does it all start?

Did you know that insufficient documentation is one of the leading causes of payment errors for therapy services?

When a patient is admitted to any facility, there will be a meeting to discuss the medical and functional status as well as goals and interventions for that patient. The interdisciplinary team (IDT) come together on admit to form the plan of care (POC) including the team consisting of,

• Physicians
• Nurses
• Therapists
• Dieticians
• Social workers

The plan of care (POC) forms the basis of care and services that will be carried out to help the patient reach his/her fullest potential before discharge. The POC does change based on the patient’s individual care needs and will be revisited regularly. It is imperative that the entire IDT is aware of the POC and follows it.

What might a discrepancy look like?

Therapy notes and nursing notes need to be reflective of the services warranted by the patient. If therapy is saying one thing about a patient but nursing is saying another, then there will be an issue with receiving payment because of questionable services.

So, let’s say a patient is admitted to a SNF and is a two-person assist with transfers. Therapy documents this as well as the therapy provided. Now, let’s say a nurse comes in and inadvertently documents the same patient as a one-person assist with transfers. 

This starts the domino effect. The next nurse comes in and doesn’t look closely at the POC, and she continues to document one-person assist based on the previous nurse’s note. Before long, several nurses have documented one-person assist. Now, we have an issue!

As you can see there is a discrepancy. There will likely be an issue with reimbursement of services if this issue is not corrected before being submitted to CMS.

I know you may be thinking, this would never happen to me! As busy as healthcare can be and especially with staffing shortages, mistakes like this can and do happen! This type of mistake can also lead to safety issues too.

How can we prevent these types of errors?

Every healthcare worker involved in the care of the patient must be on the same page, understanding the patient’s needs, and documenting correctly. This includes the certified nursing assistants (CNAs) and restorative aides. 

A large majority of the time, CNAs are doing transfers throughout the day with patients. CNAs are also part of the IDT, and their charting needs to also be accurate and reflective of the patient’s care when charting activities of daily living (ADLs). Some facilities do allow CNAs to chart in the medical record, but this varies depending on the type of facility. 

Regardless, any IDT member involved in a patient’s care must understand the care the patient requires as well as the goals and interventions set for the patient in order to assist the patient in achieving the best outcome possible in the safest way. This also ensures the facility is reimbursed accordingly.

One last note!

We all like to be paid well and get raises too, right? 

Ensuring that our documentation is accurate and consistent across all disciplinary teams helps our facility get paid for the services we are providing. Timely reimbursements factor into how we are paid and any potential raises.

So, documentation is not only to help our patients but also to help ourselves in the long run!