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Documenting Cues and Skilled Services

Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, CFPS

January 5, 2016

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Question

Does documenting lets say "verbal cues" justify skilled services in treatment notes?

Answer

As therapists, we may think that is skilled, and many times it is skilled, but can nursing also provide verbal cues?  Yes, they can.  They can provide tactile cues.  It will be very important any time you are using a cueing strategy that you identify why you are using that cueing strategy.  An example seen frequently in notes is "Bed mobility training, performed supine to sit with mod assist" .  Nursing can do bed mobility training and they can certainly assist a patient to move from supine to sit with mod assist.  A better statement might be “Tactile and verbal cues 50% of the time for logroll to maintain neutral spine and avoid counter-rotation of the lumbar spine.”  Another explanation of verbal cues physical therapists and physical therapist assistants may frequently use would be to have “accurate hand or foot placement during a mobility activity” or “for visual recognition of architectural barriers and verbal cues to successfully navigate around them.”  


kathleen d weissberg

Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, CFPS

In her 30+ years of practice, Dr. Kathleen Weissberg has worked in rehabilitation and long-term care as an executive, researcher, and educator.  She has established numerous programs in nursing facilities; authored peer-reviewed publications on topics such as low vision, dementia quality care, and wellness; and has spoken at national and international conferences. She provides continuing education support to over 40,000 individuals nationwide as National Director of Education for Select Rehabilitation. She is a Certified Dementia Care Practitioner, a Certified Montessori Dementia Care Practitioner, and a Certified Fall Prevention Specialist.  She serves as the Region 1 Director for the American Occupational Therapy Association Political Action Committee and adjunct professor at Gannon University in Erie, PA. 


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