Q
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Can you please give some examples of documentation that shows the unique skill of a therapist in a maintenance scenario?

A: Lisa Miliken: “There is a great list of suggested skilled terminology to use for different clinical scenarios on the ASHA website: http://bit.ly/1Xc5BD1 Basically, you want to show the reviewer that you are using your professional skills to teach/train the patient and the caregivers/staff, with your skills, which no one else could teach. Your skills are proven through your documentation with active skilled verbs such as: “instruct,” “analyze,” etc. Some examples listed on this site are: – Instruct patient and caregiver in use and care of communication system. – Develop maintenance program—to be carried out by patient and caregiver—to ensure optimal performance of trained skills and/or to generalize use of skills. – For patients with chronic or degenerative conditions, evaluate patient’s current functional performance; provide treatment to optimize current functional ability, prevent deterioration, and/or modify maintenance program” Learn more about this, and other related topics in the course “Audit Proof Your Skilled Therapy Documentation”.

About the author

Lisa Milliken, MA, CCC-SLP, FNAP, CDP

Lisa Milliken, MA, CCC-SLP, FNAP, CDP

Lisa Young Milliken, MA, CCC-SLP, FNAP, CDP has served as a practitioner, regional manager, vice president, consultant, compliance director and education specialist.  She has lectured at the state and national level with over 300 professional education courses on topics of importance to the healthcare professional.... Read More

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