Re: Documentation in LTC facility

Amy Greengard — Wed, 10 Jun 2009 17:03:07 GMT

Hi Jeanette,

I would suggest your company/co-workers look at Medicare transmittal 88, effective date 1/1/08, implementation date 6/9/08. Subject: Therapy Personnel Qualification and Policies related to Medicare B services. In the transmittal it is written progress notes and discharge notes are to be written by the clinician (physical therapist)(meaning either the physician/NP or the physical therapist for physical therapy services).

PTA should not be writing progress notes or discharge summaries for Medicare B clients.

Hope that helps answer your questions. Good luck.

Amy

Documentation in LTC facility

Jeanette Petitti — Fri, 08 May 2009 12:06:03 GMT

I have a couple of questions, I hope someone can help me with.

I currently work in a LTC facility that uses a lot of PRN PTA's, I am the only full time PTA. My question is: I was recenly asked to fill out a weekly summary on a patient b/c the PRN PTA did not complete it before leaving on a Friday (the PTA was there on this day). The patient was seen M-F the week before and was put on my case load the following Monday. I had not seen this patient prior to this. I did not feel comfortable filling out the weekly summary for a week of care I was not envolved with. I guess what I would like to know is, who should fill out the weekly summary (this was a Med B patient). I am not looking for confrontation at work, but I don't want to put my lic in jeopardy either. Any thoughts on this?

My second question is, does anyone know the guidelines about PTA's completing discharge summaries? I have never worked under a PT that expected me to fill out a D/C summary until now, and I am not sure that is in my scope of practice. Any help would be appreciated.

I live in PA if that matters.

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Re: Documentation in LTC facility

Documentation in LTC facility