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Progress tracking documentation for

speech, occupational and physical therapists

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The First Step

Reporting patient progress by-the-numbers is a first step and the most basic component of learning healthcare. Progress tracking provides a method for visualizing the clinical process. By-the-numbers, which includes a one to seven severity level reporting, turns ordinary documentation into a decision-making solution for patient care.

Instead of managing patient care with isolated documentation snapshots at varying intervals during the patient care process, a comparative progress-tracking approach creates clinical movies of patient response to treatment over time. Documentation by-the-numbers becomes a clinical partner by promoting effective patient care decisions to stay the treatment course, modify the existing treatment approach or seek an alternative solution. Progress tracking improves the efficiency and adds clarity to the treatment process.

Documentation supports the reported progress numbers while defining clinical effort and adding accountability to the Care Plan process. Reliable patient performance information should be reported using test/retest measures, percentage response or clinical judgment. The best numbers come from consistently applied measurement criteria documented similarly from one reporting period to the next. Narrative information should provide the detail associated with numeric progress status.

Understanding the Changes

The TreatWrite August subscriber seminar ties CPT and G Code reporting with by-the-numbers and narrative documentation. Join us for Modifier Mania, as we untangle the web of modifiers reported in association with CPT and G Codes and how to create successful and supportive documentation by-the-numbers.

[1] C. Grossmann, W. Alexander Goolsby, L. Olsen, J. McGinnis, Engineering a Learning Healthcare System; A Look at the Future, Workshop Summary, The National Academies Press, 2011

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