Purpose:
To guide therapists on the use of the FUNCTIONAL TESTS AND MEASURES section of the Physical Assessment to objectively track progress throughout the patient's home health episode.
Question Intent:
The FUNCTIONAL TESTS AND MEASURES section is intended to present a wide variety of evidence-based functional tests for each therapy discipline. Based on patient presentation the therapist will select one or multiple tests to perform and document the test results in this section.
Once test results are entered, they should be included in the THERAPY GOALS/STATUS as well as interpreted in the ASSESSMENT of the note.
Per Medicare Benefit Policy Manual Chapter 7 - Home Health Services, the Therapy Goals/Status portion of our notes helps support that "the condition of the patient will improve materially in a reasonable and generally predictable period of time. Improvement is evidenced by objective successive measurements." This is essential in our Restorative Therapy documentation.
Response – Specific Instructions:
At Routine (11) visits the Therapist will select Functional Tests and Measures in the Physical Assessment whenever a functional test is performed to document that the test was completed:
This will prompt a list of functional tests available for the therapy discipline. In the example below, the therapist selected the BERG FUNCTIONAL BALANCE SCALE as indicated by the green checkmark:
Once the functional test(s) are selected the system will prompt the therapist to complete the test in the system:
Once the test is completed the total score/results (when relevant) will be displayed. Please document these results in Therapy Goals/Status and interpret them in the assessment/plan later in your note:
Functional tests should be tracked and documented throughout the patient’s home health episode of care. To assist with this, all functional tests will be entered into Therapy Goals/Status. Below is an example of the TUG in Therapy Goals/Status. Note that the patient has progressed from 34 seconds to 26 seconds, meeting the short-term goal which has now turned purple.
Lastly, Functional Tests are to be interpreted in the Therapy Assessment/Plan. Below is an example of the TJG improvement interpreted:
