Questions and Answers from Webinar on Keys to Improving Your Documentation of Skilled Care by Writing Better Goals and Using Standardized Tests

August 3, 2018
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Which standardized tests are recommended for patients who are non-ambulatory?

The standardized assessment should support the treatment plan and demonstrate achievement of the goals. Listed below are standardized tests that can be used for low level functioning patients.

  • Sitting Balance Scale – This test assesses the functional abilities related to sitting balance.
  • Function in Sitting Test – This assessment quantifies sitting balance. A patient’s performance on various functional sitting tasks is assessed.

  • Elderly Mobility Scale – This assessment includes standing and walking components. You may have a patient who is non-ambulatory on initial evaluation, but the expectation is that the patient will become ambulatory.
  • Biceps Curl Test – This is a test of UE strength that correlates to UE function.
  • BORG Rating of Perceived Exertion Scale- a way of measuring physical activity intensity level.
  • Any recommendations for inpatient/skilled nursing therapist (OT) for writing goals for mobility in room or to therapy gym to capture our time with patient that don’t coincide with PT goals?

    It is important that OT goals for mobility are written to support a specific functional task. This will differentiate the goal from general mobility in a PT goal. The OT goal should primarily focus on getting to the destination and not on the act of walking. The functional mobility goal for OT would be coded to something other than “gait training”. Choices might include: 97535 Self Care Management if the goal included walking in the bedroom to retrieve clothes for dressing, or 97537 Community Re-integration if the goal is for ambulation on the sidewalk, in and out of doors and up and down curbs to focus on preparation for returning to shopping or other specific community tasks that were important for the patient.

    Any recommendations for objective tests for OT for ADL/IADL in an inpatient/skilled nursing setting?

    Here are some recommendations for OT:

  • The Kohlman Evaluation of Living Skills (KELS) is a standardized test designed to determine a person’s ability to function in basic living skills.
  • AM-PAC – The function in three domains is measured; mobility, daily activities, and cognition.
  • Modified Barthel Index (MBI) – This assessment measures performance in ADL.
  • Stroke Impact Scale – This assessment measures stroke recovery in eight domains including strength, hand function, mobility, ADL, emotion, memory, communication, and social participation.
  • Assessment of Motor and Process Skills (AMPS) – Training is required to administer this assessment. The AMPS is an observational assessment that evaluates motor and process skills.
  • Functional Reach Test – The test can be administered while standing or sitting (Modified Functional Reach).
  • Action Research Arm Test – This assessment measures ADL, coordination, dexterity, and upper extremity function.
  • Cleveland Scale of Activities of Daily Living – This test evaluates basic ADL in a person with dementia.
  • Executive Function Performance Test (EFPT) – This test was developed to determine a person’s ability to perform IADL tasks necessary to live independently in the home.
  • Performance Assessment of Self-Care Skills – This is an observation-based performance rating of ADL function.
  • Can you give examples of co-morbidities affecting goal setting?

    Assume a scenario where a patient with a recent diagnosis of right femoral neck fracture is referred to therapy. Suppose this patient has a co-morbidity of Parkinson disease, hemiplegia from a prior cerebrovascular disease, or multiple sclerosis. Any one of these co-morbidities may impact the patient’s performance in therapy and goals the patient is able to achieve requiring the usual plan of care to be modified. Timeframes for goal expectations might be extended. The patient may not achieve independence and goals might be set for an assistance level. There might be greater focus on family and caregiver education and goals might be set for demonstration of safe caregiver importance.

    If a patient has dementia or even mild cognitive impairment, he or she may always need at least supervision for mobility and self-care due to their cognitive status. The patient with a previous hemiplegia may not return to the prior level of functioning. If this patient was ambulating with a single point cane and had instability which resulted in a fall and femur fracture, a long-term goal may be ambulation with a walker instead of a cane.

    A patient with diabetes may not heal as well and goals may need to be extended. A patient with fibromyalgia or chronic pain may be overly sensitive to pain and goals may need to be adjusted for incremental improvement.
    When establishing goals, account for co-morbidities and their impact on the patient’s rehabilitation potential. Be realistic when setting goals.

    If you have 7 STG and LTG goals, do you need to address every goal at every therapy session?

    There are no specific CMS regulations that state every goal needs to be addressed at every therapy session. However, as stated during the webinar, best practice is for each short-term goal to be addressed during each treatment session. This is the best way to achieve progress towards each goal and demonstrate reasonable and necessary care. If you can’t address each short-term goal during each therapy session, you probably have too many short-term goals.

    I would like to know recommendations for the acute care setting regarding updating scores on standardized testing as well as goal writing for standardized tests. Often (perhaps more often than not) the therapist does not know that the visit will be the last encounter (maybe 2nd or 3rd visit only and sometimes eval is only encounter) with that patient and the patient will continue therapy either in home health or subacute facility.

    In an acute hospital setting, a typical standardized test is the “6 Clicks”. This tool was developed at the Cleveland Clinic as a short form of the AM-PAC™ (Activity Measure for Post-Acute Care™). This test is used during the initial evaluation by PTs and OTs, where six short questions determine a baseline for mobility and self-care to support the extent of therapy that is required by the patient. The initial objectives were to determine appropriate referrals for PT/OT, guide discharge recommendations, and improve allocation of therapy resources and personnel in the acute care hospital. In an acute setting, one would not be using standardized tests to measure progress and support goals due to the typically limited number of sessions.

    You mentioned it is a good idea to avoid writing too many short-term goals. Do you have a recommendation for number of goals to be written? For instance, would writing 2 short term goals and 2 long-term goals be sufficient for a plan of care? (I am working on being efficient instead of “wordy.”)

    A best practice is to limit the LTGs to one or two goals. One of those LTGs MUST be the G code choice. Then prioritize STGs to ones you can achieve in the timeframe prior to the next progress report period (10th visit), that will take you towards meeting the LTG. Usually two to three STGs can be met in a 10-visit period. Then the therapist would either upgrade those met goals or write new ones for the next progress reporting period. This pattern would demonstrate progress towards the LTGs, reasonable and necessary care and demonstrate the skills of the therapis