Detailed inpatient notes

[topwise]

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CMS's proposed new regulations as of Jan 2010 requires a particularly detailed note and care plan to be provided for every rehab patient.

I was wondering if anyone has a template available of the sort of note that CMS now requires?

Thanks.

 

[Llenroc]

Yeah it's real simple. You walk in the room, you say, "You didn't have any problems right?" While they're walking up you put the stethoscope here and there, grab their legs, then you walk out within 20-30 seconds.

S: Pt. had no new c/o this a.m.

O: Vitals go here
Gen - Awake, alert, NAD
CV - RRR
Lungs - CTA B
Abd - Soft NT
Ext - Calves supple (I'm not even sure why I write that, "supple" is something I associate with lipstick advertisements. I was just told to write that instead of "Warm, NT" 😕 )

A+P : 1) 56 yo WM s/p getting bonked to the head - IPR
2) - 4) Look up some meds and put their indications in here e.g. HTN - Lisinopril.
5) Prophylaxis - Lovenox, Protonix.

(BTW - Don't put more than 5 points down. Why? Cuz.)

Llenroc, MD

That's how it's done. 👍

No but seriously though, they did implement some changes at our institution this year. When dictating H&P's, we have to give an extended statement about why the patient is in rehab. Something to the effect of "The patient is admitted for IPR. He will receive 15 hours of PT/OT each week, for an average of 3 hours each day. Therapists will work to advance gait, mobility, ADL's, transfers." There might be additional changes too, but it's too much to remember. 😴

 

[MSKmonky]

On the first day of admission I usually type of a patient-specific template with the regular S.O.A.P. as well as a section for Functional Goals, Therapy Orders, and Precautions. Save it on a google doc file and pretty much just modify that everyday. Saves so much time. They are often lengthy.

Our consult service came up with an amazing template as well however I'm not sure if I'm allowed to share it. PM me.

 

[LTS6776]

Below is basically the template I've been using. I cut and paste from my old notes so it isn't as time consuming as it appears.

• Interval medical history:
• Interval functional history (brief summary of functional status from therapy notes):
• Subjective: and denies pain, difficulty sleeping, constipation or other complaints.
• Exam:
• Data reviewed: interval therapy notes, labs, etc...
• Assessment/Plan:

Rehab Diagnosis:
Impairments:
Precautions:
​

Patient X continues to require intensive interdisciplinary inpatient rehabilitation. He requires further PT and OT to improve strength, functional mobility, and independence with ADLs. He remains limited by .... and medical supervision of his rehabilitation is required due to.... He continues to require 24h nursing for safety, pain control, and bladder/bowel care. He continues to require close physician management for.....

and then any changes in rehab or medical plan.

 

[PMR 4 MSK]

Below is basically the template I've been using. I cut and paste from my old notes so it isn't as time consuming as it appears.

• Interval medical history:
• Interval functional history (brief summary of functional status from therapy notes):
• Subjective: and denies pain, difficulty sleeping, constipation or other complaints.
• Exam:
• Data reviewed: interval therapy notes, labs, etc...
• Assessment/Plan:

Rehab Diagnosis:
Impairments:
Precautions:
​

Patient X continues to require intensive interdisciplinary inpatient rehabilitation. He requires further PT and OT to improve strength, functional mobility, and independence with ADLs. He remains limited by .... and medical supervision of his rehabilitation is required due to.... He continues to require 24h nursing for safety, pain control, and bladder/bowel care. He continues to require close physician management for.....

and then any changes in rehab or medical plan.

Seriously, every day?

I'm never going back to inpatient.

 

[LTS6776]

Just three times a week, which is what the rules require. The midlevels write shorter notes the other days.

 

[topwise]

Thanks, everyone. I'm not doing inpatient right now and hopefully I'll get a heads up what to write when I do (soon), but I'm just trying to be proactive about it.

 

[truthseeker]

Yeah it's real simple. You walk in the room, you say, "You didn't have any problems right?" While they're walking up you put the stethoscope here and there, grab their legs, then you walk out within 20-30 seconds.

S: Pt. had no new c/o this a.m.

O: Vitals go here
Gen - Awake, alert, NAD
CV - RRR
Lungs - CTA B
Abd - Soft NT
Ext - Calves supple (I'm not even sure why I write that, "supple" is something I associate with lipstick advertisements. I was just told to write that instead of "Warm, NT" 😕 )



A+P : 1) 56 yo WM s/p getting bonked to the head - IPR
2) - 4) Look up some meds and put their indications in here e.g. HTN - Lisinopril.
5) Prophylaxis - Lovenox, Protonix.

(BTW - Don't put more than 5 points down. Why? Cuz.)

Llenroc, MD

That's how it's done. 👍

No but seriously though, they did implement some changes at our institution this year. When dictating H&P's, we have to give an extended statement about why the patient is in rehab. Something to the effect of "The patient is admitted for IPR. He will receive 15 hours of PT/OT each week, for an average of 3 hours each day. Therapists will work to advance gait, mobility, ADL's, transfers." There might be additional changes too, but it's too much to remember. 😴

Not trying to be a jerk here but I just read the thread on the DPT and there was some sentiment that PTs can't really be considered the go to professional for MSK disorders. Your post, although probably tongue-in-cheek illustrates a certain attitude. Not sure how much management and oversight you would be doing here regarding the PT and OT and SLP given that you have indicated (and others in this thread have indicated) that you are not interested in really supervising or managing these patients.

 

[RUOkie]

Not trying to be a jerk here but I just read the thread on the DPT and there was some sentiment that PTs can't really be considered the go to professional for MSK disorders. Your post, although probably tongue-in-cheek illustrates a certain attitude. Not sure how much management and oversight you would be doing here regarding the PT and OT and SLP given that you have indicated (and others in this thread have indicated) that you are not interested in really supervising or managing these patients.

No I think you are trying to be a jerk here.

Llenrock's post was clearly tongue-in-cheek as evidenced by his/her use of smilies. 😴👍

What this post is about has NOTHING to do with the actual supervision that a physiatrist does on an inpt. unit. It has to do with how do we go about making our documentation fit into the box that CMS forces us into. I speak with and supervise the plan of care of all of my patients on the inpt unit. BUT that has nothing to do with how I document.

 

[Ludicolo]

Agree. I took it as a joke, and a rather astute comment on the ridiculousness that is proper documentation for inpatient billing purposes. Documentation has (d)evolved to become simply a means to pay the bills and to CYA, and is becoming less and less associated with quality care and communication between physicians and other health care providers.

And I’m sure any documentation on the rehab management and oversight can be addressed during the weekly team conference. God how I don’t miss those.

 

[lobelsteve]

Hence, the triple response of Lobel.

The chart will be separated into 3 sections.
1. The billing chart- it includes LMN, ICD9, CPT info only, and dumbed down for the idiots reviewing for appropriateness of care to get paid.

2. The medicolegal chart- it includes brief patient information to make sure that the legal pitfalls of care are wrapped up in a tidy package. Mostly consents, risks and benefits of every action/order/treatment.

3. The Dr-Dr chart- it tells what is going on, what the plan is, and what is really wrong with the patient. It needs to be for physician eyes only (DO-MD) and not discoverable or available for insurance, patient, or the courts.

 

[PMR 4 MSK]

.

3. The Dr-Dr chart- it tells what is going on, what the plan is, and what is really wrong with the patient. It needs to be for physician eyes only (DO-MD) and not discoverable or available for insurance, patient, or the courts.

Good luck with that part...