Updated: May 23, 2020
This article will present two sides and SPOILER – no solid conclusion! Don’t worry, it’s very informative and worth the read!
Point of Service Documentation (POS) In skilled nursing settings, therapists are told they need to complete POS documentation. Point of Service documentation is a fancy name for doing your documentation while you are “treating”/providing interventions to your client. It helps increase your productivity. Productivity rates are typically high in SNF and do not provide much allotted time to complete documentation without doing it during your client’s session. Additionally, non-productive time that is given doesn’t count for all the call bells you may answer, time you spoke to the nurse, finding wheelchairs, using the restroom, etc. Quality of care suffers if you don’t have time to do any of those basic tasks. Can you be ethical AND do point of service documentation? (& productive?!) IT’S A HUGE ISSUE.It’s a source of ETHICAL TURMOILforMANYtherapists out there. If you join any Occupational Therapy skilled nursing Facebook group, you will see a TON of questions asking:
“How can I get better at it?
– “Am I being ethical?”
“What exactly am I billing for anyways?!”
“I’m a new grad and NO ONE told me or taught me that this was a thing! Should I resign?”
And – You will see FIGHTS.Fights about whether POS documentation is possible. Whether it should be done. And – You will see name calling.One side is calling anyone with a high productivity that is ABLE to handle POS documentation, “unethical.” The other side doesn’t appreciate the shadeand argues that point of service documentation can be a valuable part of a treatment session. They provide tips and tricks for making it work and stress the importance of properly educating the client and making them aware of their progress, reiterating goals frequently, and keeping accurate data. Background You Need Before We Explore Both Sides Productivity Productivity is known as billable time. Billable time is the amount of time that is spent providing direct patient care. The more productive time, the more money the rehabilitation company can bill insurance for. What does 90% productivity look like? Most of us work an 8-hour day. So…we will use 8 hours for this example.
8 hours = 480 minutes
90% of 480 minutes (90% productivity of an 8-hour day) = 480 x .90 = 432 minutes of productive time; 480-432 = 48 minutes of unproductive time/documentation time/additional getting stuffz done time.Good luck!
For this example, let’s say we have 9 patients today. Calculate productive time left divided by number of patients (432/9) = 48 minutes time with each patient
Time needed to walk and find each patient – let’s approximate 4 minutes (I’d say this is low!) For this example, we are seeing 9 patients, therefore 9 x 4 minutes = 36 minutes. We now have 12 minutes of non-productive time left. (48 – 36 = 12 minutes)
You must sign-in and check the charts for any change in medical status, check with the nurse for interdisciplinary communication purposes. Let’s give you 2 minutes per patient. 9×2 = 18 minutes. You are now at NEGATIVE 6 minutes.
You also must document your sessions. Let’s allow for 3 minutes per patient. 9x3minutes = 27 minutes. You are now at NEGATIVE 33 minutes. We have to get our notes done, so maybe we just skip our 30-minute lunch.
We are also co-signers for our beautiful OTA/COTA practitioners. Don’t forget to read all their notes, contact them if something needs correction.
So, IS THIS a POSSIBLE example that works? Let’s try again and rearrange things so they work. 7 patients = 0 minutes finding people (maybe transport delivers patients to you) + 14 minutes talking to nurses +21 min documentation = 35 minutes of non-productive time needed out of 48 minutes available. (13 minutes of bathroom/water time) 5 patients = 20 minutes finding people + 10 minutes talking to nurses + 15 minutes documentation (3 min per note) = 45 minutes of non-productive time needed out of 48 minutes available. (3 minutes of spare time) Obviously, this calculation changes based on productivity percentage, number of patients, the actual number of minutes the patient has (each patient differs & my example puts everyone at the same time) and the amount of time it takes you to type up your documentation and do other things (put your bag away in the morning, print your schedule, find wheelchairs, find nurses, find equipment, transporting patient, clocking in, out, for lunch, bathroom breaks, etc.). It doesn’t take intoaccount for any unforeseen events – what if your patient has an emergency? What if you need to use the restroom? BUT here’s a BIGGIE for me! NEWSFLASH:This calculation DOES NOT take into account any billing concerns! Billing Concerns During Your Sessions You cannot bill for documentation, but YOU CAN document while SKILLED service is occurring. (Of course, there are many skills we provide that demand our full hands-on attention and you cannot document while doing them.) To restate: You are billing for the intervention your patient is doing under your supervision while you document. Rest Break Documentation The Center for Medicare Services (CMS) states that you should STOP the billing clock UNLESS you are doing SKILLED therapy. Skilled therapy during a rest break can include patient education or monitoring of vital signs. NOTdocumenting. I find that despite which side of the issue you stand on, both SIDES often DO NOT realize that you MUST provide SKILLED therapy and STOP THE CLOCK when you are NOT. Side 1: It’s impossible! See above. There are SO many things that need to be done in one day. I can see how this side argues that we aren’t providing our best to our clients with such high productivity expectations. Unethical – I see this as unethical if you aren’t being careful about billing concerns, are billing for transportation and non-POS documentation, and are not stopping the clock when treatment is no longer skilled. This article is meant to present the sides, not make a decision for you. With that being said, I am including a list of non-billable tasks under the “It’s impossible!” section. Additionally, I am pasting in two REALLY INTERESTING and two TYPICAL real-life concerns/examples from Occupational Therapists on Facebook. Non-billable Tasks
Attend care plan meetings with social work, nursing, home health company representatives, recreational therapists, family members, patients, etc. to provide a status update.
Screenings – you SHOULD be allotted non-productive time for all screenings with DOR permission.
Documentation including: evaluations, progress notes, 30-day recertifications, and discharge notes
Weekly department meetings, meetings with Director of Rehabilitation, yearly performance reviews, and yearly human resources meetings
Consulting with the interdisciplinary team (social workers, psychologists, substance abuse therapists, speech therapists, physical therapists, etc.)
Writing orders to update frequency and/or duration of sessions.
In-services education for CNAs, Nurses, new staff, or family members
Deal with computer problems, try to find a computer that isn’t being used, download new software
Preparing patient education and home exercises sheets for your sessions
Supervise fieldwork education students
File paperwork in paper charts
Complete required continuing education courses
Checking email, bulletin boards, and notes
Grabbing someone water
Answering call bells
Your schedule doesn’t work out smoothly – no one can be seen between 12-1pm because it’s lunch time or 4-5pm because they were out of the building, in the shower, working with another healthcare professional, visiting family, etc.
Real Life Concerns: Anonymous Facebook Posts: INTERESTING Anonymous Post 1: “Rolled up patient pant leg prior to using Omni cycle (seated bicycle). After a few minutes I walk 15 feet away to get a laptop for POS documentation. Patient’s leg must have come down because it got caught up on a part of the pedal and caused injury requiring stitches. After a week suspension, I’m told to come back to work and I will be written up for “failure to act which resulted in patient injury”. I feel this write up is bulls**t because I acted immediately. And the patient was injured because of poor design of the exercise equipment combined with the patient’s poor skin integrity. Should I have to sign this write up, do I have to sign it? Any thoughts on this scenario would be helpful.” INTERESTING Anonymous Post 2: “Is it legal for a company to ask you to clock out in between patients? For example, if you’re waiting for a patient to finish a meal or activity? This is how the company wants 100% productivity.” TYPICAL Anonymous Post 3: “Does anyone have tips on how to accomplish POS documentation? I have the worst time trying this because I like to be engaged with the patient the entire time and if I’m typing I feel like I am cheating them out of valuable therapy time. I am a PRN COTA in a SNF but will be starting regular hours there in 2 weeks. I need all the help I can get.” TYPICAL Anonymous Post 4: “The push for productivity at our SNF is getting pretty intense. The past 2 months have been low census for rehab Med A’s and overall Med B caseload. Recent staff meetings include how low our revenue for B caseload is, and subsequent push for caseload. Prior to the low census I know off the clock documentation was occurring, and now more therapists are doing so to meet productivity. I was approached regarding my own %, I stated that I try to maintain an ADL focus and POS documentation is not possible most of the time, and I will not engage in unethical documentation. I am so fed up with these expectations and the desire to provide skilled and appropriate care. Signs stating that clinicians are supposed to meet their productivity are posted daily, including a listing of all therapists’ individual percentage. They also post that they will have to have daily meetings with individuals not meeting their productivity. So frustrated.” Side 2: You can do it! This side argues that you should be spending more time showing the patient that they are making progress, discussing goals, and working together. If you’d read my article entitled, “Are You Convincing Your Clients that your Services are Worth it?” You know that I am a big advocate for showing value to our clients! Your client should have a clear indication of WHY therapy is benefiting them and HOW it is benefiting them. Recommendations for doing POS
Inform your client that you will be taking notes during the session in order to get the best records
I recommend spending the last 5 minutes of the session going through everything with the client, discuss what was documented, what the goals are, and what tomorrows goals are. – Safety is a priority. The leg bike example is a clear indication of that. With that being said, I don’t believe that POS should be done with every client. You need to use your clinical judgment when deciding who and when it will be appropriate. Productivity does not trump safety EVER.
Conclusion SNF is moving toward a model that encourages increased functional outcomes. Some critics question whether not providing full attention is the best way to increase quality outcomes. Some argue that doing documentation while seeing a patient is neglectful and can harm the clients. They state that it hinders attention, active listening, and thorough observation of the client. Others argue that it can no longer be considered client-centered care. The other side believes it helps us be more transparent during our sessions. It’s worth the few minutes needed and can be made a skilled intervention when you engage the client. It helps OT show value in their services. It restates the role of OT in the health community. It also verifies and reviews all that has happened in the session. Call me crazy, but maybe we should be fighting for the right to bill “indirect patient care”. After all, lawyers bill indirect services. Dentists have codes for modalities while present and modalities while not present. Doctors can bill OT codes. I can’t help but think that there is a better way that is perhaps a little outside of the box.
I know this is a hot discussion. Let’s get the discussion going down below.
Have you used POS documentation? Do you think it is possible? Does your company have realistic benchmarks? Do you have any tips or tricks? I would love to hear your thoughts and perspective.