Rehabilitation Best Practice Documentation
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1 Rehabilitation Best Practice Documentation Click on the desired Diagnoses link or press Enter to view all information. Diagnoses: Reason for Admission to Inpatient Rehab CVA Deficits Fractures Secondary Diagnoses Intraoperative and Postoperative Complications Hematoma due to a Procedure Dementia Skin Ulcers Pressure Ulcers Diabetes Mellitus Diabetes Mellitus and Complications / Manifestations Contact the following for any documentation questions or concerns: CDI: Shannon Menei HIMS Coding: Kim Seery
2 Reason for Admission to Inpatient Rehab Best practice documentation requires the specific condition for which the rehabilitation service is being preformed. If the condition for which the rehabilitation service is no longer present, the appropriate reason for aftercare should be documented. Examples include but are not limited to: Rehab following a CVA the specific deficit (i.e. hemiplegia) Aftercare following (specified) joint replacement Rehabilitation for Fracture (specify fracture) Debility/ADL/Mobility issues identify the underlying condition causing the debility Convalescence/strengthening following surgery identify the surgery performed and link the reason for Rehab and the deficit to the surgical procedure
3 CVA Deficits Specify deficit (s) Cognitive deficits Aphasia Dysphasia Dysarthria Fluency disorder Other speech and language deficit Monoplegia Hemiplegia or hemiparesis Other paralytic syndrome (specify) Apraxia Dysphagia Facial weakness Ataxia Other specify Specify type of CVA: Infarction Nontraumatic Intracerebral hemorrhage Nontraumatic subarachnoid hemorrhage For monoplegia, hemiplegia, and other paralytic syndromes, document side affected as: Dominant - right, left or bilateral Nondominant right, left or bilateral
4 Fractures Best practice documentation for fracture diagnoses has many new key components to accurately reflect the severity of your patients injury. Type Traumatic Healing status for subsequent encounters Pathologic With routine healing Location Left, right, bilateral Specific bone Specific portion of the bone Acuity With delayed healing With non-union With malunion Etiology Place and Cause of Injury/Fracture Open Underlying pathological cause Closed Displaced Non-displaced Associated complications, such as: Nerve injuries DVT/PE Acute blood loss/blood vessel injury Hardware/Device related
5 Secondary Diagnoses During the Rehab encounter patients may be treated or managed for additional diagnoses. Any diagnosis treated and/or managed should be documented to the appropriate specificity supported. The following are frequent diagnoses encountered with documentation specificity needs identified: DVT Specify vein affected and laterality Specify if this is related to a recent surgery Infections Document organism associated to the infection (E. Coli UTI) Postop Hematoma Specify exact site of the hematoma Specify tissue type involved: Skin, subcu, muscle Specify the procedure this is related to Malnutrition Specify severity: Mild, moderate or severe Refer to Dietitian Malnutrition Progress note for severity and clinical criteria Skin Ulcers Deficits Specify underlying cause (Pressure, Diabetes, PVD, etc.) Specify site and laterality Specify depth of tissue involvement Link to the underlying cause
6 Rehab Documentation Examples Insufficient Documentation Best Practice Documentation Quadriparesis secondary to spinal cord injury post-cervical decompression and fusion. Quadriparesis secondary to spinal cord injury at C4-C5 and C6-C7 with anterior cord syndrome, post-cervical decompression and fusion. Admitted for Rehab s/p CVA with residual right hemiparesis Admitted for Rehab s/p acute left pons infarct with residual increased right hemiparesis. Patient is right hand dominant.
7 Intraoperative and Postoperative Complications The terms Post Op and Status Post are considered vague and require further clarification to determine if in fact the condition is a complication. The key elements needed for best practice documentation include: The affected body system The specific condition Acute blood loss anemia Accidental laceration (of specified organ) Hematoma Ileus Whether the condition is a/an Complication of care or due to the procedure Expected procedural outcome When did the complication occur Intraoperatively Postoperatively
8 Post-op Complications Documentation Example Insufficient Documentation Best Practice Documentation Patient VQ scan positive for pulmonary embolism. Ultrasound positive for DVT of the right femoral vein. History of TKR two weeks ago. Postop pulmonary embolism and right femoral DVT most likely resulting from immobility from recent TKR.
9 Hematoma due to a Procedure Site of the hematoma Depth Skin Subcutaneous tissue Musculoskeletal Procedure associated with the hematoma The clinical significance of the hematoma considered a postoperative complication or an expected outcome Unrelated to the procedure o o Due to other chronic condition Due to anticoagulants
10 Dementia Identify the type of dementia Vascular dementia Includes: o o Arteriosclerotic Multi-infarct Dementia due to a specific disease, such as: o o o o Alzheimer s Disease Early Onset Late Onset Parkinson s Disease Alcohol Dependence AID s Document any associated Behavioral disturbance Aggressive Combative Violent
11 Skin Ulcers excluding Pressure Ulcers Best practice documentation requirements for skin ulcers requires a provider to capture all of the key elements in their documentation Underlying Etiology Diabetic PAD/PVD Venous stasis Associated Manifestations Cellulitis Gangrene Osteomyelitis (acute, chronic) Depth Limited to skin breakdown With fat layer exposed With muscle necrosis With bone necrosis Site / Location/Laterality Present on Admission Status
12 Pressure Ulcer Site/Location/Laterality Stage I-IV, Unstageable Associated Manifestations Cellulitis Gangrene Osteomyelitis (acute/chronic) Present on Admission Status
13 Diabetes Mellitus To accurately capture the severity of illness and risk of mortality of your Diabetic patient you must document all of the key elements associated with the condition including: Type Type 1 Type 2 Drug/chemical induced Due to underlying condition Due to genetic defects of beta-cell function Due to genetic defects of insulin action Post-pancreatectomy Postprocedural Control Inadequate control Out of control Poorly Controlled Hypoglycemia Hyperglycemia Insulin use
14 Diabetes Mellitus and Complications / Manifestations Diabetic manifestations must be linked to the diagnosis to establish a cause and effect relationship. Manifestations and Complications Diabetic retinopathy Diabetic Osteomyelitis Diabetic PVD With Diabetic Ulcer Diabetic peripheral neuropathy With Diabetic Ulcer Diabetic nephropathy Diabetic gastroparesis Diabetic ulcer and/or gangrene Diabetic Hyperosmolarity With or without Coma Hyperglycemia/hypogl ycemia With or without Coma Diabetic Ketoacidosis With or without Coma
15 Key Documentation Concepts Link reason for admission/deficit to associated surgery, injury or illness. i.e., Aphasia due to CVA Document any associated manifestations or conditions needing treatment or management i.e., malnutrition, DVT, UTI, delirium, pressure ulcers, etc. Document progress of patient daily Be as specific as possible when documenting any diagnosis
16 Take the Extra Step! Document : ALL chronic conditions present and stable but managed. Significance of abnormal tests (i.e.: UTI, electrolytes, echo) Clarify whether diagnoses are ruled in or ruled out Establish cause-and-effect relationships (i.e. PICC line infection) Laterality, if applicable Explain the why and because to support medical necessity Any tobacco use, abuse, dependence, history of smoke exposure (e.g., second hand, occupational, etc.)
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