Medical Speech Pathology

Curiosity, Dialogue, and Knowledge

Words Words Words


My father told me what his seminary professor told him; he said, “Son, fall in love with words.  You can do whatever you want to, if you can master them.”

Of the many things my father told me to do, this may be one of the few that stuck.  There is, in fact, nothing more important to a speech language pathologist. We obsess about words so much that we break them into sounds, blends, proto-words, MLUs, graphemes, morphemes, and (if we could do it) into the very atoms that make up the sound waves in the air.

The words I’m writing about in this post are more about what words are important when we document.  In graduate school we all learn how to write technically about a patient.  We adopt an observational tone and manner of writing that allows us to pass on information to another clinician if/when services transfer to someone else.  We also make sure that we note a patient’s progress towards goals we’ve set forth.  We don’t, however, always get a lot of good information on how to document so that we are reimbursed appropriately.  We also have little-to-no savvy when it comes to understanding how Medicare decides how long someone can stay at our hospital, SNF, or rehab facility.

When it comes to the SNF and acute hospital setting, I can’t speak to the specifics like I can about an IRF (inpatient rehabilitation facility).  In an IRF, we use the Functional Independence Measurement (FIM) instrument.  This allows us to rate someone’s level of independence or dependence on a scale of 1 (dependent) to 7 (independent).  When Medicare (and insurance agencies) look at how long it should take a patient with a given diagnosis to recover enough functional abilities to go home, they look at scores on this scale to make that determination.

So how accurate do you really need to be with FIM?  One point can make all the difference.  There are 18 different items to score for any patient.  A patient with a new stroke, for example, could get 20 days of rehab or 30 days of rehab all decided by one lousy point.  That could mean all the difference in level of assistance needed: nursing home or home.  Which would you want for your family member?  I won’t dive into all the complexities of the rating scale, but suffice it to say that is a minor adjustment, a subjective appraisal of one motor area that can cause a patient to lose 10 days of rehab with a stroke of a pen.

This post, then, is to encourage all of the medical professionals out there to pay attention to the details of reimbursement and care management.  There is more to therapy than just therapy.  If we want the best outcomes for our patients we have to focus our efforts on consistent, accurate, and careful documentation.  To do any less than this, is to sell our patients short.


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