Purpose:
Co-Morbidities will be assessed at each subsequent visit after the initial evaluation visit. The primary intent of this pathway is to make sure clinicians are addressing any potential condition that may result in a patient’s hospitalization. As a therapist, you need to consider other conditions that may need to be addressed at visits outside of the primary therapy issue to ensure the patient will not be adversely affected. Below is the entire list of options to select from. The following instructions highlight one at a time with details on how to complete.
Response – Specific Instructions:
Selection one would be used if there are active comorbidities, but based on your thorough assessment they are managing them properly with no need for education. Make sure you confirm they are truly managing these safely before selecting this item.
Selection two would be used if there are medication potential issues. For therapy, for example a patient on antihypertensive medications who is not following MD orders, can potentially impact therapy as the patient’s BP may be uncontrolled precluding the prescription of activity. So, a patient who is prescribed Hydrochlorothiazide may need to be reminded on when and how to take the medications and the adverse side effects if the therapist finds the patient is not taking it properly. Here is an example of what would be filled out, “Patient reminded to take medication twice a day per MD order. The patient has not been consistently taking the medication as prescribed. Communicated with RN Mary regarding today’s findings. Patient verbally confirms understanding following prescription”
Selection three, this looks at a therapist addressing any condition exacerbation. So for example a patient who is being seen primarily for balance and gait training due to OA but has history of CHF is noted to have increasing edema in her leg. Therapist finds the patient is not doing daily weights and watching salt. Therapist may document “Patient instructed to resume her daily weights and not consume foods high in salt. Patient reports eating bags of potato chips lately what were not salt free. Patient verbally repeats understanding.”
Selection four, this looks at educating the patient to report symptoms changes to the provider. This is to ensure there are no missed potential warning signs that could lead to a hospitalization. For example, the therapist may be concerned about potential DVT for a total knee patient and document the following: “Patient was instructed to notify therapist immediately if temperature elevates greater than 100, has pain in calf, redness and or increased swelling in lower left leg. Patient was able to repeat back 3 times a 100% to therapist for accuracy.”
Selection five, that there are no active comorbidities and thus doesn’t need to be addressed.