Chapter 10. Pediatric Documentation | Effective Documentation for We are also a CMS recognized PQRS registry, we automate the reporting of PQRS and Functional Limitation G codes and provide automatic alerts for plan of care expirations, authorizations, progress note reminders and KX modifier alerts. Post exercise OT assessed and measured gross grasp: 40# L, 42# R, tip pinch 7# bilaterally (an improvement of 2# each hand for gross grasp and 1# improvement bilaterally for tip pinch from last session). Discharge from PT x Continue PT 2 x per week for 3 weeks. 0 10+ Therapy Note Templates - PDF Increased time needed for proper positioning prior to exercise to ensure optimal execution of task. No matter how many years of experience you have in this field, you need to show your distinct skill in your documentation. 1. Patient instructed in BLE recumbent bike training to increase overall functional activity tolerance and LE strength to maximize balance and reduction of falls during mobility. CPT 97112 means "neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.". Most of the difficulty in writing defensible documentation lies in the assessment section. This means that your documentation should: Explain your reasons for choosing group therapy, including in each patient's plan of care explicit justification for choosing group therapy as an adjunct to individual or concurrent therapy. Patient educated on purpose and instructed in Codmans exercise x 1-minute x 5 RUE clockwise, then counter clockwise. Here are the top ten things you should know about providing Maintenance therapy. Because Physical Therapists deserve to go home to family, not paperwork. Progress to minimal 40 second planks next session but encourage patient to complete to point of fatigue.