Examples of Documentation of Skilled and Unskilled Care for Medicare Beneficiaries

Speech-Language Pathology Services

The following examples of skilled and unskilled documentation are used to illustrate Medicare guidelines that state that all services must be medically necessary and be provided at a level of complexity and sophistication that requires a speech-language pathologist to perform the tasks. For more information, see Documentation of Skilled Versus Unskilled Care for Medicare Beneficiaries.

Examples of Information to be Included In Documentation of Skilled Services

To document skilled services, the clinician applies the tips listed below.

Use terminology that reflects the clinician's technical knowledge.
Indicate the rationale (how the service relates to functional goal), type, and complexity of activity.

To address word retrieval skills, patient named five items within a category. A limit of 12 seconds made the activity more complex than that tried in the last session.
Because patient has residue in the mouth with solids, putting them at risk to aspirate that material, they performed tongue sweeps of the buccal cavity with minimal cues on 80% of solid boluses.

Report objective data showing progress toward goal, such as

accuracy of task performance (e.g., 50% accuracy in word retrieval in sentence completion tasks);
speed of response/response latency (e.g., patient demonstrated 7–10 seconds of delay for auditory processing of sentence level information; delay reduced to 3 seconds with supplemental written cues);
frequency/number of responses or occurrences (e.g., patient swallowed 6/10 PO trials of ½ tsp boluses of puree textures with no delay in swallow initiation);
number/type of cues (e.g., initial phoneme cues provided on half of the trials);
level of independence in task completion (e.g., patient verbally described all compensatory strategies to maximize swallow safety independently, but required minimal verbal cues from SLP/caregiver to safely implement them at mealtimes);
physiological variations in the activity (e.g., patient demonstrated increased fatigue characterized by increasingly longer pauses between utterances).

Specify feedback provided to patient/caregiver about performance (e.g., SLP provided feedback on the accuracy of consonant production; SLP provided feedback to caregiver on how to use gestures to facilitate a response).
Explain decision making that result in modifications to treatment activities or the POC.
- Indicate dropped or reduced activities (e.g., cuing hierarchy was modified to limit tactile cues to enable greater independence in patient's use of compensatory strategies at mealtimes).

Explain how modifications resulted in a functional change (e.g., patient's attention is enhanced by environmental cues and restructuring during mealtime, allowing her to consume at least 50% of meal without redirection).
Explain advances based on functional change (e.g., coughing has decreased to less than 2x/6 oz. drink; liquids upgraded from nectar to thin).
Indicate additional goals or activities (e.g., speech intelligibility remains impaired due to flexed neck and trunk posture and reduced volume; goals for diaphragmatic breathing will be added to POC to encourage improved respiratory support for verbal communication and increased volume of phonation).

Elaborate on patient/caregiver education or training (e.g., trained spouse to present two-step instructions in the home and to provide feedback to this clinician on patient’s performance).
Evaluate patient’s/caregiver’s response to training (e.g., after demonstration of cuing techniques, caregiver was able to use similar cuing techniques on the next five stimuli).

Examples of Skilled and Unskilled Documentation

Treatment Notes

Motor Speech

Goal
Improve speech intelligibility of functional phrases to 50% with minimal verbal cues from listener.

Unskilled treatment note
Pt continues to present with unintelligible speech. Treatment included conversational practice. Recommend continue POC.

Comment: This treatment note does not provide objective details regarding patient's performance.

Skilled treatment note
Pt continues to have unintelligible speech production; unable to consistently make needs known. Intelligibility at single word level: 60%; phrase level: 30%. Pt benefits from SLP's verbal cues to reduce rate of speech and limit MLU to 1–2 words. Listener has better understanding if pt points to 1st letter of word first. Pt demonstrated improved self-awareness of intelligibility relative to last week's session.

Aphasia

Short-term goal
Pt will produce one-word responses to functional wh- questions x 60% with min cues.

Unskilled treatment note
Pt produced word-level responses with 70% accuracy in treatment session with verbal cues.

Comment: This note does not include modification of the plan of care based on patient performance and does not detail skilled treatment activities.

Skilled treatment note
Word level responses to wh- questions to:

self and ADLs: 70% accuracy
semantically abstract questions: 50% accuracy

Benefits from phonological (initial syllable) cues but unable to self-cue successfully. Naming nouns is better than verbs. Performance improves when pt attempts written response to augment verbal output to facilitate phone-grapheme associations.

Dementia

Short-term goal
Pt will use compensatory strategies for orientation to time to reduce agitation with 80% accuracy when cued by staff

Unskilled treatment note
Pt recalled events that occurred earlier today with 50% accuracy.

Comment: This treatment note does not support the short-term goal in the plan of care.

Skilled treatment note
Spaced retrieval techniques were used to train pt to locate calendar, check clock, and look on whiteboard for daily schedule. Pt responded to temporal orientation questions relating to personal history (x 50% accuracy) and schedule at current living environment (x 60% accuracy) with mod verbal cues provided by SLP/caregiver. Pt benefitted from verbal rehearsals to improve independence in use of compensatory strategies.

Voice

Short-term goal
Pt will communicate in phrase level utterances x 10 with appropriate vocal quality, pitch, and loudness to indicate wants/needs.

Unskilled treatment note
Pt tolerated speaking valve for 30 minutes.

Comment: There is no clear connection between the daily note and the short-term goal.

Skilled treatment note
Speaking valve was placed to help facilitate verbal communication. Pt repeated 10 phrases without visible signs or symptoms of respiratory distress for 30 minutes. Pt's SPO2 level maintained 99%-100% during the entire session.

Progress Notes

Cognition/Executive Function

Short-term Goal
Pt will use compensatory strategies to record upcoming appointments with 90% accuracy.

Unskilled progress note
Pt was given an appointment book for recording upcoming appointments. Continue established POC.

Comment: This note does not report the patient's performance and provides no description of modification or feedback.

Skilled progress note
A 3-step process was provided in writing to help patient go through the steps of recording appointments in their pocket calendar. They practiced with trial appointments until they replicated the 3 steps with 100% accuracy with minimal verbal cues.

Dysphagia

Short-term goal
Pt will safely consume mechanical soft diet with thin liquids x 3 meals per day with ≤ 1 overt s/s of aspiration to meet all nutrition/hydration needs.

Unskilled progress note
Pt has been tolerating mechanical soft/thin liquid diet well.

Comment: This progress note does not reflect change in status as a result of skilled intervention.

Skilled progress note
Pt has been seen for 8 treatment sessions during this period. Pt's diet was upgraded from puree/nectar thick liquids to mechanical soft/thin liquid diet. Pt safely consumed 3 trial meals at lunch with no overt signs and symptoms of aspiration. Pt requires mod verbal cues to safely implement compensatory strategies. The short-term goal has been updated to include trials of regular texture foods. Plan of care includes caregiver education prior to discharge.

Discharge Notes

Dysphagia

Unskilled discharge note
Pt has made progress during treatment. Pt and spouse educated on use of swallow strategies for safety. Recommend discharge SLP services at this time.

Comment: This note does not detail skilled intervention, patient's functional change in status, or skilled aspects of caregiver training.

Skilled discharge note
Skilled SLP services included caregiver education, dysphagia management, therapeutic diet upgrade trials, compensatory strategies (pacing, full oral clearance, cyclic ingestion, relaxation technique for controlled breathing) and discharge counseling. Pt currently has orders for mechanical soft with thin liquids x 2 meals (breakfast/lunch) but remains on puree at dinner. Significantly reduced swallow safety noted in evening due to increased cognitive-behavioral changes associated with sun-downing. Pt and spouse educated re: compensatory swallow strategies to improve safe and efficient swallowing with 100% return demonstration of strategies by the spouse. SLP educated pt and family on the need to implement relaxation strategies while eating due to pt experiencing anxiety during meal times. Recommend pt returns home with home health SLP services to address swallow safety while maximizing efficient PO intake on mechanical soft diet with thin liquids.

The interpretation of Medicare guidelines and examples above are consensus-based and provided as a resource for members of the American Speech- Language-Hearing Association.