Maintenance Therapy Documentation Examples

In an insurance-regulated world, good documentation is essential to demonstrate the medical necessity and skill of therapy services that are rendered. This becomes even more critical for patients receiving maintenance therapy as, patients who exceed the therapy threshold are "more likely to come under medical review".

Stuck on what to write? Here are some examples using a "what" / "why" / "how" approach specific to patients receiving maintenance therapy.

 Skilled Documentation for Maintenance Therapy Samples

The recommended therapy requires clinical judgment and skill to provide the proprioceptive neuromuscular facilitation [skill] and manual therapy techniques [skill]  to increase ROM, improve neuromuscular efficiency, and protect the patient from further decline from immobility and the medical sequelae of contracture while maintaining her current level of independence [maintenance benefit].  These activities could not be safely done by the patient or caregiver as improper execution can result in failed outcomes and injury to the patient [why it cannot be taught]

The recommended therapy requires clinical judgment  [skill] to provide caregiver training [what], task adaptions [what] and environmental modifications [what] to improve patient/caregiver safety [why], reduce aggressive behaviors [why] and allow the patient to participate in self-care and meaningful activities (why) with appropriate supervision and assistance so that patient can age in place.  [functional outcome].

The skill and expertise of the clinician is required to provide maintenance therapy care due to the complexity of the interventions and the evolving needs of the patient and caregiver.

NuStep x 8 minutes [what] to mimic reciprocal gait pattern [why] and increase LE muscular endurance [why] to prepare the patient for functional mobility in home. [outcome]. O2 monitored throughout [skill and safety] and provided cues] [skill]  for upright posture to maximize cardiopulmonary function [why].  Monitored patient vitals and O2 stats throughout the session to ensure safe performance [why a therapist is needed].

Selected [judgment] AROM for BUE all joints and ranges followed by BUE strengthening using 2 lb weights 3x10.   Monitored [skill] patient performance and provided verbal/manual cues [education] to ensure correct technique [why].    Determined [judgment] that the program could be advanced and added 5 additional reps for elbow flexion/extension exercises.  Introduced [judgment and skill] red theraband 3 x 10 for horizontal abduction and elbow extension with activities designed so that patient can unload groceries and place in kitchen cabinets independently [the goal]

NDT techniques were provided for the LUE/LLE to decrease spasm-spasticity [goal]. With facilitation [skill], decreased tone and pain are noted [benefit]  and the patient was able to reach 90 degrees (supported) of horizontal abduction with slow progressive stretch [functional outcome]. In supine, patient was able to maintain a prolonged stretch for the performance of PROM/AAROM with therapist controlling and monitoring movements to ensure correct anatomical plane [skill].

Dynamic standing balance activities [what] performed in kitchen to improve balance [why] eliciting ankle strategies [skill] with verbal cues for midline posture [education] to reduce fall risk [why]. Added [judgment] reach above shoulder level activities to simulate unloading groceries [functional outcome].

ROM:  Maintain current ROM [what] to prevent joint contractures, ulcers, and other medical sequelae of immobility [functional outcome].  Due to presence of spasticity and hypertonicity, patient is at risk for injury if performed incorrectly by unskilled caregiver [why]. 

STRENGTH: Maintain strength of UEs/LEs at 3+/5 [what] through grading and selection of an individualized exercise program [how] to allow patient to assist in functional transfers and for personal hygiene [why].

PAIN MANAGEMENT:  Provided craniosacral and myofascial therapy techniques [skill] to keep pain levels at 4/10 [measurable] and maintain patient at current status of PRN (1 time/week) use of opioid medication [functional outcome].

FALL PREVENTION:  Provide graded challenges to balance [what] in a therapist-controlled environment [skill] to reduce fall risk during functional mobility tasks [why]. Maintenance of current balance function requires that balance be challenged, but doing so places patient at risk for falls or injury unless performed by a skilled therapist [voila]!

... happy documenting :-)