Multidisciplinary Team Documentation

“…Ensure that the patients receive close medical supervision and furnish through the use of qualified personnel, rehabilitation nursing, physical therapy, and occupational therapy, plus, as needed, speech therapy, social services or psychological services, and orthotic and prosthetic services.”
CMS Manual System –Pub 100-04; Transmittal 221

  • Tie medical conditions to rehab therapy and medical clinical care to rehab
  • Multi-disciplinary plan of care
  • Three hours
  • Rehabilitation nursing

Documenting an Interdisciplinary Plan of Care

“The hospital uses a coordinated, multi-disciplinary team approach in the rehabilitation of each inpatient, as documented by periodic clinical entries made in the patient’s medical record, to note the patient’s status in relationship to goal attainment…”
CMS Manual System –Pub 100-04; Transmittal 221 Plan

  • It is more than numbers
  • All disciplines working toward common goals that are found in barriers resulting from medical and functional issues, causing the admission
  • Team Conferences
    • Documentation of medical conditions and impact on rehab progress
    • Rehab functional progress relative to goals and relative to last meeting
    • Readjustment of goals based on progress
    • All disciplines including nursing attends, reports and signs plan of care/team conference meeting notes
    • Make part of the medical record


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