Screening: The patient's condition is assessed to determine whether therapy would reduce the patient's pain and discomfort, or enhance current level of function.

Performance Standards:

Communicate with nursing to identify patients who have fallen or had a decline in function.

Screen all patients quarterly.

Screen new patients or patients who are re-admitted to the facility

Print screen form using SMART.

Schedule time to perform screens on patients

Review patient's chart to gather necessary information (i.e. prior level v, current level of function).

Perform visual assessment of patient.

Ask patient about their complaints or concerns.

Gather information from nursing staff regarding patient's level of function and/or problems or concerns.

Upon completion of screening, determine need for therapy services or environmental modifications.

Make recommendations to therapy team members regarding the need for therapy services.

Check patient's chart for lead in documentation.

If no therapy services are needed, follow up with patient on a regular basis to ensure patient is maintaining highest functional level.

Evaluation: The patient's condition is evaluated and a customized rehabilitation and treatment plan is devised to address specific needs and goals to attain the highest level of function.

Performance Standards:

Make contact with patient within Medicare timelines.

Review patient chart for medical history, physician's order, treatment diagnosis, prior level of function, medications, precautions, etc,

Assess current level of function and identify deficits.

Interview patient and caregiver.

Based on objective findings, provide appropriate treatment diagnosis that will substantiate medical necessity.

Identify reasonable prognosis and any barriers that limit the patient's ability to achieve prior level of function.

Set short term and long term goals that are measurable.

Develop treatment plan, determining frequency and duration of treatment.

Create discharge plan based on patient's anticipated functional progress.

Patient Care: Individually designed programs of physical treatment are carried out to maintain, improve or restore physical functioning and alleviate pain in patients.

Performance Standards:

Establish rapport with the patient in order to more easily motivate the patient.

Address patient's motivation and have patient actively participate in meaningful therapy goals.

Carry out plan of care with the patient through the following interventions:

Safety training with functional mobility and transfers

Postural, sitting and standing balance

Neuromuscular re-education associated with quality of LE movement, functional mobility and transfers Wheelchair mobility and positioning

LE range of motion and contracture management

Splints, adaptive equipment and durable medical equipment

Manual therapy and modalities

Strengthening and endurance training

Home exercise program

Staff/care giver education

Environmental modifications

Determine patient's deficits and needs through daily assessment of the patient and adjust treatment plan accordingly.

Promote safety in all aspects of care.

Grade activities to challenge the patient and promote independence.

Observe the patient's tolerance and reactions to treatment.

Discharge patient from physical therapy when goals or projected outcomes have been attained or as needed and provide for appropriate follow-up care or referrals.

Perform home evaluations, as needed.

Documentation: Patient's prognosis, treatment, goals, response, and progress are documented appropriately and timely.

Performance Standards:

Ensure needed orders are obtained and in medical chart (i.e. - evaluation orders, discharge orders).

Complete evaluation form (700) in a timely manner, to include patient history, treatment diagnosis, prior level of function, medications, baseline assessment, measurable long and short-term goals, discharge plans, precautions, etc.

Write a clarification order, as needed per facility policy.

Write daily notes and charges on the day the patient was treated (or after each treatment) in SMART system identifying exercises, activities and functional tasks performed during that day's treatment. Include any factors impacting treatment such as complaints, pain level, improvements, limitations and any other relevant concerns or reports, as specified by payor source.

Write weekly notes in SMART, documenting functional status of patient such as progress or decline, including any significant information from that week's treatment and update/modify goals.

Review and co-sign on PTS’s weekly notes.

Complete 701 form/update plan of care and update/modify goals every 30 days.

Document communication among disciplines, staff, caregivers or patient.

Document the occurrence of the weekly PTA/PT patient care conference to discuss patient's current POC.

Begin discharge planning by documenting patient's level of function in relation to achieving goals and discharge location.

Upon discharge, complete proper paperwork for restorative nursing program or functional maintenance program.

Document patient's discharge on discharge summary.

---