Being my cheerful self, I walked into the patient's room, introduced myself and immediately felt the frozen gazes of several family members. The one family member who could speak a little English told me it wasn't a good time to see his grandmother. I tried to get a commitment time from him but he deferred and suggested I come back later. No problem, I told myself, but later never came.

The family asked supervisors that I not come back because they didn't want someone like me to see the patient. Someone like me, in this instance, meant I'm male and don't speak the same language as them. The family specifically requested a female, fluently bilingual therapist. This isn't the first time a patient or family member has made a request pertaining to their comfort level in who treats them or their loved one. I have read about family members requesting that only white people treat their family member because of the patient's comfort level and facilities will sometimes honor the request.

When facilities begin to acquiescence to requests like this, it can interfere with the hiring of potential caregivers who have excellent patient care skills. These caregivers will travel where they are more welcome to provide their care to whoever needs it. Suppose I request only female EMTs when I call 911 because an accident happens at my home or only male CNAs for myself when I'm in the hospital? How about only male nurses and only female surgeons because I'm most comfortable with their care? Will this affect how a facility or business hires people? Yes. And it prevents extremely gifted people who are skilled at their jobs from doing what they do best.

In the instance above, it wasn't the first time I was asked not to see a patient based on my gender and limited language ability. Even with an interpreter by my side, I was asked to leave a room one time. The interpreter didn't tell me everything, but I suspected it was more than me being male and not fluent in the language they spoke. So I kept stepping, because I had work to do with people who wanted me to help them get them better.

Just because a code is billable, doesn't make it the best possible code for a therapy diagnosis. I have certificates in billing and coding and constantly come across codes, such as 719.7, which is difficulty in walking. This can be the "catch-all" code for almost any therapy patient we see in the clinics. The same with 781.92 (abnormal posture) and 781.2 (abnormality of gait).

Perhaps 729.89 (other musculoskeletal symptoms referable to limbs) could be used because it's just as vague as the other therapy diagnoses. What I'd like to see is a separate and clearer therapy diagnosis that would better reflect why the patient is being seen for therapy.

I've come across codes like 596.0 (unspecified disorder of bladder) as the main therapy diagnosis. My first question is why would an insurance company pay for therapy services on a patient with a bladder infection? It doesn't make sense, but then again I'm not a PT who decides the diagnosis of the patients, am I? If I was the insurance carrier, I wouldn't pay for any rehab services when the best therapy diagnosis to justify treatment is a bladder infection.

If the PT isn't sure what the best diagnosis is for the patient, he should ask. Based on the evaluation, there could be several, more specific diagnoses to better justify therapy services. Some clinics may have a coder who can accurately code the patient with the best diagnosis and possibly receive a higher reimbursement rate because the patient is coded correctly. I'm sure there are many MD health clinics that hire coders specifically for that reason. With direct access, it seems that providers would want to ensure all codes are specific to the patient's condition and not some vague weakness code that seems so prevalent in the clinic today, like 780.79 (other malaise and fatigue).

I've tried wearing different brands and styles of shoes in the clinic that will protect my feet and stand up to the demands I place on them. Every single pair have split at the ball of the foot due to those demands.

I hesitate to wear sport-type shoes because I don't think they look professional enough in the clinic. I like the feel of Italian leather against my foot and the comfort it provides but any dress-type of shoe seems to wear out just as quickly as the sport shoes I've worn in the past. I want the shoes I wear to complement the outfits I wear so I look professional to clients, nurses and doctors, yet I want to be comfortable when I'm moving around in the therapy gym. Tennis shoes don't work for me unless I'm mowing the lawn or walking the dog.

I've worn boots, which were comfortable but not practical in the clinic. With my supinated foot and sometimes weird gait pattern, I tend to reshape any footwear I try on almost immediately. Currently I have slip-on shoes, which are easy to get on and provide some comfort to my sensitive gait pattern, but they're almost worn out at the ball of the foot as well. I'm not sure if there's a footwear company that can handle the demands I place on my shoes -- providing me with support, comfort and most of all, a professional appearance.

Therapy can be monotonous at times, especially if I'm seeing too many total joint replacements. Don't get me wrong, I love what I do, but going through the same routine every day can be a bit boring. I will try and break up the session of therapy and do the exercises in the morning and the higher-level balance activity in the afternoon. Anything for a change like going outside, entering and exiting vehicles, up two flights of stairs etc. And as soon as patients are independent with their exercise programs, it's time to have fun.

I usually start by telling them they have to attain a certain amount of points before they can go home. As they look at me quizzically, I tell them they'll also have an essay to write about their surgery and to absolutely ensure they leave the facility, they'll need to remember everyone's name. Most of the time they understand it's a joke and when I begin to smile, then they fully understand I'm not serious.

When certain patients are in the process of leaving and packing their room, I'll stop by and tell them there's a change of plans and they'll have to stay another week and do more therapy. This usually gets them packing quicker and pushing me out of the room. At this point, most of the patients I see know I'm mischievous and like to have fun.

Years ago, when I was a bit more serious and stern about what I did, a patient told me, "You should have more levity in what you do because you deal with so much from so many." It wasn't an instantaneous change for me to "lighten up." As I got more comfortable in the work environment, felt more at ease and better able to understand what I know and don't know, that's when the change occurred. The other therapists I worked with had a lot to do with it as well and some of the fun we had in the department naturally rubbed off during patient care.

Sometimes I'll be the one to initially assess a patient who requires increased intervention by nursing. In a SNF, patients can fluctuate in ability, cognition and activity level, which is often first seen by the therapy department. Typically one of us will see something unusual and discuss the patient among ourselves after we've notified nursing of the potential change in the patient. I've worked with brilliant therapists who have been so concerned about the patient's well-being, they'll call the MD rather than wait for nursing to make the call.

Whether it's me or some other therapy person who first notices a change, we seldom stand up on a pedestal and proclaim our Mensa membership. The assessment of a patient is a group effort based on the skill and experience of the whole department. Many times I've notified the PT with a concern about a patient's joint-replacement healing wound and redness associated with it. After a look by the PT, we then determine the next course of action and treatment. Both my and the PT's assessment have value and will directly benefit the patient involved.

While I was working per diem at one place, I assessed a patient in regard to increased pain and swelling in her knee. I may have been the first therapist to actually touch her leg since the evaluation. The patient often wore pants so her leg was not immediately accessible when watching her move through the range. I like to see surgery sites on patients so I can make note of them in the chart. I asked her to remove her pants and yes, it took time and effort but was well worth it.

I might have saved the patient's leg with that extra time. What surprised me most was that nursing didn't see what her knee looked like first. Then I realized the full-time therapist should have caught this as well. The patient knew it did not look right and may have kept it hidden from nursing and other therapists in the hope it would clear up by itself. I'm glad I was there to help her. But it wasn't only my assessment that noticed her knee, it was the combination of being educated and instructed by all the brilliant therapists I've had the pleasure of working with all these years.

This year I want to hear from fellow PTAs. I want to know your thoughts on healthcare changes, working relationships with PTs, and your ideas about increasing the PTA education to a bachelor's level as well as your feelings towards the APTA and the PTA profession.

I would ask that you do a bit of research on reimbursement rates in Kansas for PTA services and also peruse the APTA website for their RC 3-11 and the use of support personnel to provide therapy services. In addition, take a look at your state's rules and regulations concerning the PTA. There are often small nuances regarding whether we, as PTAs, have a scope of practice or not. (Some would say PTAs have a scope of work, not practice, they must abide by).

The use of PTA services has been instrumental in providing care throughout the country but there are some who would like to see all therapy services provided by PTs only. This thinking seems naive in the sense that a skilled PTA with more than 10 years of patient care experience is not considered a valuable commodity regarding the care and treatment of patients in all settings. In a business sense, we're cheaper compared to the wage a DPT would want coming out of school. However, please take a look at this abstract and let me know what you think.

Also think about which settings are and aren't appropriate for the PTA. When I was on one of my clinicals, I was in the pediatric ICU where PTAs are not generally allowed to perform their skills. But if I'm not supposed to be in the pediatric ICU, why did the PT take me in there? And why am I allowed to perform therapy in the adult ICU where the risk and acuity is just as high?

Let me know your ideas and thoughts about the PTA profession and how we can make it better for the patients. I can be reached at PTABlogTalk@gmail.com

As we approach a new year, a Festivus miracle occurred ("Seinfeld" enthusiasts will understand this). I had an epiphany about how to be a better therapist in 2013. At first, it made about as much sense as a Chris Elliott book but as I began to unravel what I wanted to do, I made a vow to be a better person in the coming year.

I decided to learn one new skill a month. It will not necessarily have to be a therapy skill but one that will relate to some of the patients I see in the SNF. I made a list of skills I wanted to learn and before I knew it there were more than 20. As I pondered this list, I whittled it down to 12 skills that I thought would benefit me and help me better relate to the patients I see. I also wanted the skills to be things that I have no knowledge about, like crocheting. In addition, I wanted to learn these skills on my own with limited involvement of others. That way, I can make mistakes and correct them to improve on how I do things. I will seek guidance only when I can't figure out how to do something on my own.

Yes, I could learn all about the nervous system or relearn muscle origin and insertion or take multiple fall prevention courses, but to really improve my relationship with my patients I wanted to learn a skill they may have that I don't. I already have a vague knowledge of multiple skills unrelated to therapy that have helped me relate to many patients to get them motivated and moving to go home. The challenge I set for myself this coming year was to learn 12 brand new skills that I can also pass on to others as well as help me with patient care. It sounds simple enough and I'll keep you updated on my progress periodically throughout the year.

In the mail, I received several brochures advertising how to evaluate and treat multiple body parts. All therapy disciplines were invited to attend. Being a PTA, I don't evaluate people so I wonder if I could get a discount because the evaluation aspect of those courses wouldn't directly benefit me in my chosen profession.

I'd like to see more courses directly related to what I do -- assessments and treatments. I've seen generic courses related to orthopedics and fall prevention that would be beneficial but very few that are geared specifically to the PTA. Assessments are an important aspect of what I do. I need to accurately report any changes in the patient's condition to the PT in charge so if any updates to the POC are warranted, the PT can act immediately based on my observation of the patient's condition.

Changes in a patient's condition can occur rapidly in acute care and a PTA who can note and report seemingly insignificant data in that change of condition can actually save a person's life. Even in a SNF when a patient casually reports chest pain, an assessment should be done immediately to assess a greater medical concern. Precision in a PTA's assessment is paramount to a therapy department's success and experienced PTAs who can pick up subtle changes in a patient's condition are definitely leaders in their field.

The first time I heard a nurse call for security, I quickly ran to the room and assisted to keep a patient settled down. At first, I thought the patient quieted down because I was there but as I turned there was a large burly gentleman who took up the doorframe with his arms crossed. The patient was looking directly at him and immediately became compliant while we restrained him so he would not pull out the various IV tubes.

At that point, I became interested in security issues from a health provider's point of view. While working in various hospitals, I noted cameras at entrances and exits by doorways and down some corridors, while most doors were secured with a numerical lock. Inside the hospital, some areas were restricted and required a swipe card attached to a name badge to enter. There was usually a security detail driving around or walking the perimeter of the facility as well. As I ventured into the world of SNFs, I noted a significant decrease in cameras and generally no security detail.

I did some research related to nursing homes and shootings and began to wonder why security seems so lax in a place that cares for the elderly and others who are unable to care for themselves. Some of the shootings were murder-suicide situations but the deadliest took eight lives (seven residents and one nurse) and injured three others. Could security measures have stopped this?

Cameras around the perimeter of a facility can deter some criminal activity but numerical locks or card swipes for outside doors will stop people from entering a facility. This can make visiting a loved one more like entering a lockdown unit than a residential care home but the safety of the residents, patients and staff is the utmost concern. What do you think -- should more safety measures be taken at the facility where you work?

A facility I worked at had one computer. It was used for clocking in and out, as well as to organize a schedule for us. At the time, we weren't using it for documentation but we had to input minutes under the CPT codes. It was also used for new therapists to watch the orientation DVDs.

At any given time, there were between one and four per diem therapists and at least one new person watching the DVDs on the computer. There were six full-time staff members as well so you can imagine the wait toward the end of the day to use the computer. Often I would wait to input the data until the next morning, figuring the company would be mad if my productivity was in the 60s because I waited an hour to use the computer. Shortly thereafter, I was asked to input the data before I went home. Sure enough, my productivity slipped and I had to explain why.

Now, at my house we have three computers and two laptops. At any given time, there's at least one computer free for someone to use. If I can afford to have that many computers, certainly a multimillion-dollar company should be able to afford another one for about $500. The company decided not to invest in another computer, so we made do as best we could and some of us had overtime because of the delay in using the computer.

We all tried to input data throughout the day so a back log would not occur at the end of the day, but all it took was a new hire to log in and delay the rest of us as he watched the DVDs to complete the orientation. My current employer has it right on with the use of a laptop so we can do point-of-service documentation throughout the day. How about you? Is there ever a line of therapists to use a computer in your department?

A while ago, a patient came into the facility and we were given two weeks to make the patient stronger and safer to go home. The two weeks was what the patient's insurance company authorized. Research shows that a person will need to increase caloric intake and lift heavier weights with shorter repetitions to increase strength. The person should also come to the therapy gym two to four hours a day and rotate body parts, doing chest, arms and lower-body exercises on alternate days to guarantee an increase in overall strength and performance with safe activity. Unfortunately this will not occur.

Two weeks is generally not enough time to increase strength in an older adult who is already debilitated from spending time in a hospital. Maybe I could talk to the facility's nutritionist and explain that the patient needs to eat six small meals a day with an increase in protein and fresh vegetables so therapy can achieve the goals dictated to us by the insurance company. My seven other patients are Medicare part A and are reimbursed by the minutes, not the outcome of service provided. I still have 99 more days to achieve their goals.

If the PT is supposed to direct the care of a patient, he's immediately overruled by the insurance company because they will only authorize two weeks of care. So even before a POC is written, the length of stay is dictated and any long-term goal set greater than two weeks is moot. I'm not sure if an advanced degree is required to take orders from an insurance company. Maybe I'm mistaken, I've been wrong before.

A therapist's gym is a multipurpose room not only for the staff but also patients. For the staff, it's used for in-services, luncheons and meetings. For the patients we see, the gym is used for exercises to get stronger, a place to encourage and become encouraged by others, and a safe place to express frustrations.

Often when I'm with patients in the gym, they'll tell me about their family struggles or a difficult nurse the night before. The patients open up about their lives the more they are with me in the gym. The gym becomes a confessional room of sorts where patients can express themselves to us without guilt of reprisal, although I'm quite stunned by what some of the patients have told me.

One spoke about a pipe bomb that he built and what it was for. The bomb exploded in his basement and he was being seen for wound care. He also tried to sell me an AK-47. One patient spoke of writing all her children out of the will because they were going to her house to claim items while she was in the SNF. I politely declined to sign as a witness on some forms a lawyer brought to her.

Quite a few patients have told me about medications or home remedies they've brought from home. Of course I let the nurse know about it. I'm always surprised by what a patient will tell me next when we are alone in the gym. There are patients who will complain about their families and neighbors who come to visit. I've heard so many stories and so-called "family secrets" that I could write a hundred five-minute mysteries to bedazzle even Edgar Allan Poe.

Like a lot of therapists, I have a full-time position and several per diem jobs that I go to if my caseload is low or when I need extra cash to purchase a large item. Recently I applied to a company that was paying five dollars more than what I'd normally get with a per diem position. I dutifully filed out the online application as best I could, including a detailed resume of my work history and several references.

Apparently this was not good enough. I was requested to provide email addresses to prior employers so a survey could be sent to them and they could rate my skills. I was also asked to provide exact dates of employment I had six years ago. I told the HR person they were lucky I could remember the years I worked for the various employers and it was not high on my list of things to do to provide that information. I directed them to my resume but they wanted exact dates of when I was employed. The company wanted more information from me than the state board did when they did an investigation on me, but that is a different blog.

After several weeks of no contact I was directed, by e-mail, to call a regional director to take a drug test and discuss my hours of employment. By this time I wasn't interested in being employed by the company. If it takes a month (or longer) to be hired on a per diem basis, I lose interest. If the company is desperate and in need of therapists, they really need to speed up the hiring process. If I already have work lined up with other employers, I'm not going to stop and make calls and take a drug test just for the possibility of working for an employer. One of the shortest interviews I had was less than a minute and most of that was taken up by discussing a per diem rate. Once the pay was established, I began work the next day.

How long should the interview and HR process normally take?

A PTA came up to me and asked why a patient was on caseload. The patient recently had a THA, was independent with transfers, able to follow an HEP independently and walking more than 150 feet with an SPC. Vital signs were within normal limits with activity and the patient was weaning off pain medication in preparation for going home. A home assessment had not been done on this patient and there was some question if one was even needed. I suggested the PTA talk it over with the PT and from there they could formulate a plan of care or discharge the patient.

I'm a fan of allowing the PTAs to suggest POCs and encourage them to be actively involved when discussing the patient's progress and discharge planning. Of course, the final decision is up to the PT, but a phrase like "Because I said so," is not an appropriate reason to keep a patient on caseload. There should be a functional deficit or an objective measurement we can work toward improving to show progress. When there's a question if a patient should be discharged, I look at the goals (both short-term and long-term) and assess whether the patient has met them or not. If the goals are met, the PT needs to reassess the patient and determine, with the PTA's professional input, if the patient is clinically appropriate to continue with therapy.

I've worked with PTs who will keep a patient on caseload because they know the patient's family or they both go to the same church. I've seen goals change from 300 feet of gait to 500 feet, Tinetti goals from 25/28 to 28/28 and Berg scores updated from 45/56 to 50/56. Yes, these are measureable goals but is there good clinical reasoning behind the updated goals or are they being changed just to keep the patient on therapy? And should I be questioning the clinical judgment of the PT when he updates the goals like this?

With the advent of electronic health records (EHR) and the ever-changing resources we learn through computer documentation, there doesn't seem to be a need for the SOAP-note format. In fact, if SOAP notes are still taught in therapy school it may be a waste of time because fewer and fewer places are utilizing this type of documentation.

The SOAP-note format is effective when gathering and organizing data on a patient but is not suited for some of the computer programs available. The EHR that I currently use does not specify a place for subjective or assessment information. There is, however, plenty of space for objective data collection. And there isn't a specific place in the EHR for the "P" in the SOAP note.

Several EHRs are used by different companies (I've learned four in three years) and each one seems to only want certain information documented. Most have a drop-down menu with a point-and-click sentence structure. I seldom have to type any subjective information. One place I worked had a device like a personal digital assistant that you could carry around. It allowed you to document time spent with the patient and input which CPT codes were used with a drop-down menu if you wanted to briefly add anything to the note.

Is your facility still using the archaic SOAP-note format?