Performance Measurement Network

Question: Documentation for Rehabilitation Assessment

Is documentation solely by a Physical Therapy Assistant or Occupational Therapy Assistant acceptable to determine if a patient was assessed for rehabilitation? Or, must the documentation be from a Physical Therapist or Occupational Therapist, or Speech-Language Therapist?

Answer:

Documentation by a PT or OT assistant is acceptable. Notes written by a certified nursing assistant (CNA) or health care technician (HCT) are not acceptable and excluded.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical, Related Manual - Data Quality Manual
Related documents: STK-10, Assessed for Rehabilitation Services,
File:

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