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SNF documentation ?

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SNF documentation ?

  • I'm a COTA/L in CT. I just started working per diem in a SNF on the weekends for extra income (my husband lost his job) I work during the week full time in a private pediatric clinic. The director of the rehab dept. is a PT. There is no OTR/L on site on the weekends. I was told that an OTR/L (I have met them) would be available as needed for supervision. I am also concerned about the lack of documentation. I am provided a "soft" file for each pt. Some files have the OT eval. a weekly soap note with short term/long term objectives as well as documentation of status with all areas of OT. However  most of the files do not have "dailey" notes. There is only the date at the top of the colume and the tx intials at the bottom. There is an area for "dailey" notes, but very few have any documentation in this area. When I asked the director about this he said "You only have to document if something significant happens" When I asked him like what He said "If the pt falls or has a medical problem" I did not feel comfortable with this, since I don't know these pts and I am a COTA/L only working on the weekend without a OTR on site. I looked up in my documentation books and saw that there should be a "dailey" note and at at the minimum that note should include the Date, Tx area, Pt response to tx, tx signature. When I showed this to the rehab director he told me that was not true for SNF.  He offered to put a note on the outside of each chart to let me know what the pt's status was for when I tx on the weekend. I told him I would only feel comfortable if there was if the OTR who saw the pt during the week provided a note. He refused stating that he was not going to ask his OTRs to do something that was not required. He asked me if I was going to return next weekend I told him I would let him know asap.....

    So I need to know....is a dailey note required?

    Thanks,

    Betsy        

  • Is there an Area or Regional Manager you can speak with, in order to clarify the company’s position on note writing? Or an Occupational Therapy Clinical Coordinator? Medicare A in a SNF requires a weekly note. Daily notes are helpful and many companies ask for them or expect them from practitioners. What must be in that note is up to the contract company’s owner. Can the OTR call you on Friday and tell you about the clients? Often in any setting where someone is PRN on the weekend, the regular OTR or COTA that works with the clients during the week will leave a index card or flow sheet of the client’s current status (ability, progress, needs). Communication is required, the form that takes differs. What does your license law say in regard to supervision?

     

    From: otainfo [mailto:otainfo@aota.org] On Behalf Of ebdaniels
    Sent: Monday, February 22, 2010 7:30 PM
    To: Cynthia Meyer
    Subject: [otainfo] SNF documentation ?

     

    I'm a COTA/L in CT. I just started working per diem in a SNF on the weekends for extra income (my husband lost his job) I work during the week full time in a private pediatric clinic. The director of the rehab dept. is a PT. There is no OTR/L on site on the weekends. I was told that an OTR/L (I have met them) would be available as needed for supervision. I am also concerned about the lack of documentation. I am provided a "soft" file for each pt. Some files have the OT eval. a weekly soap note with short term/long term objectives as well as documentation of status with all areas of OT. However  most of the files do not have "dailey" notes. There is only the date at the top of the colume and the tx intials at the bottom. There is an area for "dailey" notes, but very few have any documentation in this area. When I asked the director about this he said "You only have to document if something significant happens" When I asked him like what He said "If the pt falls or has a medical problem" I did not feel comfortable with this, since I don't know these pts and I am a COTA/L only working on the weekend without a OTR on site. I looked up in my documentation books and saw that there should be a "dailey" note and at at the minimum that note should include the Date, Tx area, Pt response to tx, tx signature. When I showed this to the rehab director he told me that was not true for SNF.  He offered to put a note on the outside of each chart to let me know what the pt's status was for when I tx on the weekend. I told him I would only feel comfortable if there was if the OTR who saw the pt during the week provided a note. He refused stating that he was not going to ask his OTRs to do something that was not required. He asked me if I was going to return next weekend I told him I would let him know asap.....

    So I need to know....is a dailey note required?

    Thanks,

    Betsy        



  • Medicare requires a SNF progress note every 10 days. Unfortunately the DOR is correct it is not required daily.


    From: ebdaniels <bounce-ebdaniels@aota.org>
    Sent: Monday, February 22, 2010 8:29 PM
    To: drc_cota@yahoo.com
    Subject: [otainfo] SNF documentation ?

    I'm a COTA/L in CT. I just started working per diem in a SNF on the weekends for extra income (my husband lost his job) I work during the week full time in a private pediatric clinic. The director of the rehab dept. is a PT. There is no OTR/L on site on the weekends. I was told that an OTR/L (I have met them) would be available as needed for supervision. I am also concerned about the lack of documentation. I am provided a "soft" file for each pt. Some files have the OT eval. a weekly soap note with short term/long term objectives as well as documentation of status with all areas of OT. However  most of the files do not have "dailey" notes. There is only the date at the top of the colume and the tx intials at the bottom. There is an area for "dailey" notes, but very few have any documentation in this area. When I asked the director about this he said "You only have to document if something significant happens" When I asked him like what He said "If the pt falls or has a medical problem" I did not feel comfortable with this, since I don't know these pts and I am a COTA/L only working on the weekend without a OTR on site. I looked up in my documentation books and saw that there should be a "dailey" note and at at the minimum that note should include the Date, Tx area, Pt response to tx, tx signature. When I showed this to the rehab director he told me that was not true for SNF.  He offered to put a note on the outside of each chart to let me know what the pt's status was for when I tx on the weekend. I told him I would only feel comfortable if there was if the OTR who saw the pt during the week provided a note. He refused stating that he was not going to ask his OTRs to do something that was not required. He asked me if I was going to return next weekend I told him I would let him know asap.....

    So I need to know....is a dailey note required?

    Thanks,

    Betsy        




  • Hi
    Thanks for your quick reponse:) I know that a progress note is weekly...but my understanding is that a note with the minimum of date, areas worked on, pt reponse, tx signature is required whenever a pt is seen.....I'm seeing pt on the weekend that according to their chart have been seen 3-5x AEB a tx initials under the date, but that is the only documentation for those visits.....
    Would love your continued input:)
    Betsy



    Sent from my iPhone

    On Feb 23, 2010, at 8:35 AM, "Delvin C., COTA/L, MSHE(c)" <bounce-drccota@aota.org> wrote:

    Medicare requires a SNF progress note every 10 days. Unfortunately the DOR is correct it is not required daily.


    From: ebdaniels <bounce-ebdaniels@aota.org>
    Sent: Monday, February 22, 2010 8:29 PM
    To: drc_cota@yahoo.com
    Subject: [otainfo] SNF documentation ?

    I'm a COTA/L in CT. I just started working per diem in a SNF on the weekends for extra income (my husband lost his job) I work during the week full time in a private pediatric clinic. The director of the rehab dept. is a PT. There is no OTR/L on site on the weekends. I was told that an OTR/L (I have met them) would be available as needed for supervision. I am also concerned about the lack of documentation. I am provided a "soft" file for each pt. Some files have the OT eval. a weekly soap note with short term/long term objectives as well as documentation of status with all areas of OT. However  most of the files do not have "dailey" notes. There is only the date at the top of the colume and the tx intials at the bottom. There is an area for "dailey" notes, but very few have any documentation in this area. When I asked the director about this he said "You only have to document if something significant happens" When I asked him like what He said "If the pt falls or has a medical problem" I did not feel comfortable with this, since I don't know these pts and I am a COTA/L only working on the weekend without a OTR on site. I looked up in my documentation books and saw that there should be a "dailey" note and at at the minimum that note should include the Date, Tx area, Pt response to tx, tx signature. When I showed this to the rehab director he told me that was not true for SNF.  He offered to put a note on the outside of each chart to let me know what the pt's status was for when I tx on the weekend. I told him I would only feel comfortable if there was if the OTR who saw the pt during the week provided a note. He refused stating that he was not going to ask his OTRs to do something that was not required. He asked me if I was going to return next weekend I told him I would let him know asap.....

    So I need to know....is a dailey note required?

    Thanks,

    Betsy        







  • If you feel uncomfortable working in an area where the supervision/communication is infrequent you should remove yourself from that site and seek work where you will have more contact with anther COTA or OT.

    As one gains experience in one's field then treatment areas such as this are not as overwhelming.  You should do a quick assessment and see where the patient is prior to treatment or make the assessment part of your treatment every time you treat anywhere, "Mary, can you show me how you don your robe before we head to therapy?" will let you know where they are leveled at regardlless of what was worked on prior to your treatment.  In a SNF you will see patient's who's levels change daily due to illness or medication or age related issues.  So, a note from Thur might not reflect the person you see on Sat regardless!! 

    Good luck! 

    NancyI

  • Thanks for ur quick response....I am comfortable in this setting...just want to see what documentation is required...according to books on documentation. A "dailey" note is required everytime a pt is seen...minimum of which I'd date, area worked on, pt reponse & tx signature...is this right? I just want to request from thr DOR what is required
    Thanks for your input
    Betsy

    Sent from my iPhone

    On Feb 23, 2010, at 1:03 PM, NancyI <bounce-NancyI@aota.org> wrote:

    If you feel uncomfortable working in an area where the supervision/communication is infrequent you should remove yourself from that site and seek work where you will have more contact with anther COTA or OT.

    As one gains experience in one's field then treatment areas such as this are not as overwhelming.  You should do a quick assessment and see where the patient is prior to treatment or make the assessment part of your treatment every time you treat anywhere, "Mary, can you show me how you don your robe before we head to therapy?" will let you know where they are leveled at regardlless of what was worked on prior to your treatment.  In a SNF you will see patient's who's levels change daily due to illness or medication or age related issues.  So, a note from Thur might not reflect the person you see on Sat regardless!! 

    Good luck! 

    NancyI

  • I know this is sad...but a lot of facilities ask therapists to write a daily "blurrb" to track going contact. The RUG/ billing is the "daily note" at some facilities that only require the minimum doc.


    From: ebdaniels <bounce-ebdaniels@aota.org>
    Sent: Tuesday, February 23, 2010 12:43 PM
    To: drc_cota@yahoo.com
    Subject: Re: [otainfo] SNF documentation ?

    Hi
    Thanks for your quick reponse:) I know that a progress note is weekly...but my understanding is that a note with the minimum of date, areas worked on, pt reponse, tx signature is required whenever a pt is seen.....I'm seeing pt on the weekend that according to their chart have been seen 3-5x AEB a tx initials under the date, but that is the only documentation for those visits.....
    Would love your continued input:)
    Betsy



    Sent from my iPhone

    On Feb 23, 2010, at 8:35 AM, "Delvin C., COTA/L, MSHE(c)" <bounce-drccota@aota.org> wrote:

    Medicare requires a SNF progress note every 10 days. Unfortunately the DOR is correct it is not required daily.


    From: ebdaniels <bounce-ebdaniels@aota.org>
    Sent: Monday, February 22, 2010 8:29 PM
    To:


    [The entire
  • Hi
    Sorry to continue with my ? But I need to know what is "legal" I don't want to continue @ this SNF if they are not meeting the minimum requirements for documentation
    Thanks 
    Betsy

    Sent from my iPhone

    On Feb 23, 2010, at 2:23 PM, "Delvin C., COTA/L, MSHE(c)" <bounce-drccota@aota.org> wrote:

    I know this is sad...but a lot of facilities ask therapists to write a daily "blurrb" to track going contact. The RUG/ billing is the "daily note" at some facilities that only require the minimum doc.


    From: ebdaniels <bounce-ebdaniels@aota.org>
    Sent: Tuesday, February 23, 2010 12:43 PM
    To: drc_cota@yahoo.com
    Subject: Re: [otainfo] SNF documentation ?

    Hi
    Thanks for your quick reponse:) I know that a progress note is weekly...but my understanding is that a note with the minimum of date, areas worked on, pt reponse, tx signature is required whenever a pt is seen.....I'm seeing pt on the weekend that according to their chart have been seen 3-5x AEB a tx initials under the date, but that is the only documentation for those visits.....
    Would love your continued input:)
    Betsy



    Sent from my iPhone

    On Feb 23, 2010, at 8:35 AM, "Delvin C., COTA/L, MSHE(c)" <bounce-drccota@aota.org> wrote:

    Medicare requires a SNF progress note every 10 days. Unfortunately the DOR is correct it is not required daily.


    From: ebdaniels <bounce-ebdaniels@aota.org>
    Sent: Monday, February 22, 2010 8:29 PM
    To:


    [The entire
  • Oh & what is considered a blurb? Is it more than a date & intial also what is RUG?
    Betsy
    Sent from my iPhone

    On Feb 23, 2010, at 2:23 PM, "Delvin C., COTA/L, MSHE(c)" <bounce-drccota@aota.org> wrote:

    I know this is sad...but a lot of facilities ask therapists to write a daily "blurrb" to track going contact. The RUG/ billing is the "daily note" at some facilities that only require the minimum doc.


    From: ebdaniels <bounce-ebdaniels@aota.org>
    Sent: Tuesday, February 23, 2010 12:43 PM
    To: drc_cota@yahoo.com
    Subject: Re: [otainfo] SNF documentation ?

    Hi
    Thanks for your quick reponse:) I know that a progress note is weekly...but my understanding is that a note with the minimum of date, areas worked on, pt reponse, tx signature is required whenever a pt is seen.....I'm seeing pt on the weekend that according to their chart have been seen 3-5x AEB a tx initials under the date, but that is the only documentation for those visits.....
    Would love your continued input:)
    Betsy



    Sent from my iPhone

    On Feb 23, 2010, at 8:35 AM, "Delvin C., COTA/L, MSHE(c)" <bounce-drccota@aota.org> wrote:

    Medicare requires a SNF progress note every 10 days. Unfortunately the DOR is correct it is not required daily.


    From: ebdaniels <bounce-ebdaniels@aota.org>
    Sent: Monday, February 22, 2010 8:29 PM
    To:


    [The entire
  • Blurrb= just an informal daily note of your interaction with the patient. This my may not go in the hard chart. RUG-Resource Utilization Group. It is how SNF bill Medicare Part A pts. We commonly refer to them as "minutes."

    Delvin Champagne, COTA/L, MSHE(c)
    Founder/President
    DC MD VA Rehab Pros Network
    (757) 343-1877 mobile
     
     


    --- On Wed, 2/24/10, ebdaniels <bounce-ebdaniels@aota.org> wrote:

    From: ebdaniels <bounce-ebdaniels@aota.org>
    Subject: Re: [otainfo] SNF documentation ?
    To: drc_cota@yahoo.com
    Date: Wednesday, February 24, 2010, 2:33 AM

    Oh & what is considered a blurb? Is it more than a date & intial also what is RUG?
    Betsy
    Sent from my iPhone

    On Feb 23, 2010, at 2:23 PM, "Delvin C., COTA/L, MSHE(c)" <bounce-drccota@aota.org> wrote:

    I know this is sad...but a lot of facilities ask therapists to write a daily "blurrb" to track going contact. The RUG/ billing is the "daily note" at some facilities that only require the minimum doc.


    From: ebdaniels <bounce-ebdaniels@aota.org>
    Sent: Tuesday, February 23, 2010 12:43 PM
    To: drc_cota@yahoo.com
    Subject: Re: [otainfo] SNF documentation ?

    Hi
    Thanks for your quick reponse:) I know that a progress note is weekly...but my understanding is that a note with the minimum of date, areas worked on, pt reponse, tx signature is required whenever a pt is seen.....I'm seeing pt on the weekend that according to their chart have been seen 3-5x AEB a tx initials under the date, but that is the only documentation for those visits.....
    Would love your continued input:)
    Betsy



    Sent from my iPhone

    On Feb 23, 2010, at 8:35 AM, "Delvin C., COTA/L, MSHE(c)" <bounce-drccota@aota.org> wrote:

    Medicare requires a SNF progress note every 10 days. Unfortunately the DOR is correct it is not required daily.


    From: ebdaniels <bounce-ebdaniels@aota.org>
    Sent: Monday, February 22, 2010 8:29 PM
    To:


    [The entire