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Section Navigation Part 14 of 25 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What the clinician must assess 4. Technique 5. Required data to chart 6. 4. Normal findings 7. 5. Abnormal findings 8. 6. Mode A — complete chartable narrative 9. Subjective — ask 10. Objective — observe 11. Measure 12. 8. Interventions performed 13. 9. Patient and caregiver teaching 14. 10. Response and reassessment 15. 11. Physician or provider notification 16. 12. Red flags and emergency escalation 17. 13. Skilled-need justification 18. 14. Medical-necessity statement 19. 15. Homebound relevance 20. 16. Weak vs. strong documentation 21. 17. Common audit and denial risks 22. Smart phrases 23. Normal narrative bank — stable / at-baseline 24. Abnormal narrative bank — focused / at-risk 25. 19. Sources and clinical references Previous Next 10. Response and reassessment Document the patient’s response in measurable terms — distance ambulated, strength grade achieved, transfers performed with a stated level of assistance, pain reduced from one score to another — not “tolerated activity well.”
State the reassessment plan: the strength, range-of-motion, and gait parameters to recheck next visit, the expected trajectory, and the threshold for escalation or additional therapy. When function declines, document the revised plan and the therapy coordination that produced it.
Section Navigation Part 14 of 25 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What the clinician must assess 4. Technique 5. Required data to chart 6. 4. Normal findings 7. 5. Abnormal findings 8. 6. Mode A — complete chartable narrative 9. Subjective — ask 10. Objective — observe 11. Measure 12. 8. Interventions performed 13. 9. Patient and caregiver teaching 14. 10. Response and reassessment 15. 11. Physician or provider notification 16. 12. Red flags and emergency escalation 17. 13. Skilled-need justification 18. 14. Medical-necessity statement 19. 15. Homebound relevance 20. 16. Weak vs. strong documentation 21. 17. Common audit and denial risks 22. Smart phrases 23. Normal narrative bank — stable / at-baseline 24. Abnormal narrative bank — focused / at-risk 25. 19. Sources and clinical references Previous Next 