1. Completes an evaluation of patients with basic and complex conditions utilizing standardized test and measures and including outcome measures. 2.
Develops goals that are functional, measurable, and attainable and based on patient’s limitations.
3. Creates/follows treatment plan per policy for each patient based on daily assessment and patient goals and adjusts treatment based on patient’s response, needs, objective findings, desired goals and available resources. Determines functional prognosis, and reasonable treatment duration based on diagnosis and evaluation findings.
4. Obtains and reviews all sources of pertinent information including but not limited to: physician orders, pt’s medical/social history, available reports and test results prior to initiation of treatment and as periodically as indicated.
5. Develops, instructs and reassesses appropriate individualized HEP as appropriate. HEP instruction reflects patient age, psycho/social resources, cultural factors, level of understanding, ability to read and is documented as per department policy.
6. Follows facility/site policy regarding documentation. Ensures that documentation meets minimal payer/regulatory requirements. Uses only common abbreviations that have been approved by facility/site. Documents the use of any patient restraint.
7. Records information only on proper forms and writes legibly. Records date and time and signs every note. Does not change documentation after the fact. Any changes or revisions to documentation are in accordance with facility/site policy. Documentation is factual, objective and doesn’t allow for emotions. Reports the facts in an organized and chronological manner.
8. Completes documentation for each therapy visit. Records information as close as possible to the time that you deliver care; doesn’t document in advance
9. Documents all telephone calls that are pertinent patient information. Documents all attempts to contact the referral source and/or payment source and other communications relevant to the patient.
