What are the basic elements for documentation for therapy services?
A. The necessary documentation for therapy services should include the following: • Physician Orders • Modality or type of care to be furnished • • Duration and frequency of service • Date and signed by physician • Plan of Treatment (Initial and current plan of care signed and dated by the physician) • Type and nature of care to be furnished • Functional goals and estimated rehabilitation potential • Treatment objectives • requency of visit • Estimated duration of treatment • Signed and dated by physician • Physician Certification and/or Re-certifications (Certification is obtained at the time the plan of treatment is established) • The services are or were furnished while the patient was under care of a physician. • A plan for furnishing such services is or was established by the physician, physical therapist, occupational therapist, or speech pathologist and periodically reviewed by the physician. • Services are or were required by the patient.
