Nursing and Therapy Documentation Tips. Team Documentation. What can the non-physician provider do to support medical necessity? Ensure documentation is legible and easy to navigate.
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Prior level of function
Anticipated D/C plans
Patient’s rehab expectation
Individual Functional Independence Measures with emphasis on findings
ROM and Strength limits
Sensation, tone, etc.
How do you tell the story?
Summary of findings
Thorough exam of each functional area
Report of functional deficits and the patient’s response to the loss of function
Community reintegration and inclusion plans
Response to treatment or compensatory techniques modeledTeam Documentation