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PTA Blog Talk

Goal Documentation

Published July 22, 2009 2:12 PM by Jason Marketti

"You do not need to address each goal in your daily note.  Focus on what you did that was skilled."

This is a direct quote from our DOR to me.  I really like our DOR, she is fair, concise, and a great clinician but I didn't get what this meant. 

So I asked, "How can we document progress and attainment of goals if we don't address them?"

After several more short conversations throughout the day and confusion about a progress note that was due it was decided (I assume) that I should address goals in the daily notes. 

The confusion about the progress note was a goal was not addressed in the daily notes so what should be written?  Should we write "not assessed", ignore it or make it up?  My contention is that if it was not documented in the daily notes for the last two weeks it was not addressed by anyone and I would have written that is was not assessed.  This did not sit well with the department and the PT decided to write the progress note.  I hope she didn't make it up. 

Help me out here.  Do we address goals in the daily notes or have I been doing this wrong for the last 14 years? 

 

 

3 comments

Jason,

Of course you document attainment of goals and progression of goals.  The skilled part is written to justify payment for our service. The part I hate is coming across a progress note due and when I look back at the notes there is no documentation whether the goals were addressed.  This has happened more than once.  I usually glance at the goals and try to address one or two of them like in Janey's example.

Karen July 28, 2009 12:10 AM

Thanks Janey, I do appreciate feedback and I don't expect others to always agree with me.  It helps when others have a different perspective and can explain their side.  

I have looked at notes written in the last two weeks at our clinic and some are unclear as to what skilled services were provided.  Vague descriptions of gait and exercises were given by both myself and the PT.  To justify this would be hard and a notewriting clinic may be just what we need.

Thank you for the input.

Jason July 27, 2009 9:19 AM

According to your quote, the DOR said you do not have to address "each goal in your daily note."  I would take that to mean that each goal did not need to be addressed in every daily note.  In other words, you might address goals 1, 3, and 5 on M-W-F and goals 2, 4, and 6 on T-R.  This is just a simplistic, hypothetical listing, of course.  It does not mean a goal isn't documented or addressed.  It is just to say that every daily note does not have to contain information on every goal.

The DOR's point to "focus on what you did that was skilled" may very well come from years of seeing what constitutes a denied claim.  As a regional therapy manager I had to defend claims that were denied, sometimes from notes that were written before I even came to the area.  The responsible therapist was no longer at the facility and there was no way to get in contact with him/her.  Honestly, based on the notes, I would have denied the claim too.  

That's when I began doing notewriting clinics with my therapists.  I would copy notes, removing all identifying information, and have the therapists critique them.  When you don't know the patient or the therapist writing the note - and you can critique them objectively - you'll be surprised at how little useful information many of the notes actually contain.  Addressing every goal isn't going to get the claim paid if there is no documentation of skilled service.  

We have to look at a note through the eyes of claims payer.  As a therapist we know what we did and why a CNA couldn't do it, but do we write it down?  To a claims payer, if it isn't written down, it didn't happen.  Reviewing some of those notes I realized I'd written my fair share of them.  I wondered how many notes I'd written that some other director may have had to defend and just how difficult I'd made her job.  Not intentionally, but through a lack of awareness.

Honestly, we get busy and we can get lazy about our documenting.  We would argue we aren't lazy, we're working our butts off.  And we are.  We feel it is more important to spend the time actually treating the patient rather than writing about it.  As we are writing our daily notes, sometimes dozens a day at the end of the day - and especially if we are treating patients with similar diagnoses - it is easy to get into a notewriting rut.  That rut can be costly for the facility.  We don't usually recognize our own rut.  

A notewriting clinic, critiqueing each other's notes, might be a good exercise for your DOR to institute.  But the therapists have to be willing to go in openminded and with their defenses down...realizing the point of the exercise is to improve the client's end outcome by increasing payment of claims.  If the DOR will type out the notes so handwriting can't be recognized that will help thin-skinned therapists not to feel as though they are being picked on.  Even more ideal would be if she could swap notes with a nearby facility, then noone would be able to recognize the patient or therapist involved.  The note would be standing on its own merit.

As far as "the confusion" you wrote about, your writing is so confusing in that section that I'm not completely clear on what the issue was.  I do not say that to be flip, only to point out that your message, at least to me, is unclear.  Sometimes we know exactly what happened - and we think we have accurately conveyed our message - but our point is obscured in the translation.  Perhaps the DOR sees some of that same ambiguity in your notes?

I haven't read your notes, they may be perfectly spot on.  Simply answering your call for feedback and going on the information you provided...and playing a bit of the devil's advocate in the event there is a ray of wisdom to your DOR's input.

Best

Janey Goude July 26, 2009 11:24 PM

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    Jason J. Marketti
    Occupation: Physical Therapist Assistant
    Setting: San Jacinto, CA
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