Medical Speech Pathology

Curiosity, Dialogue, and Knowledge

Documentation Dilemmas

artwork by Poontoaswaon retrieved from

In April of this year, I took a new job within my company where I scrutinize documentation and educate on how to document,  to ensure that the patients at our hospital are receiving the care and the time that they deserve.  It’s a radical departure from one-on-one patient care.  It has exposed me to a far different perspective on rehab care.

So what have I learned so far?  One fact I’ve discovered is that we have some seriously outdated regulations that count toward a patient’s co-morbidities (co-morbidities = how sick you are in addition to your main illness…e.g.- “I had a stroke –main illness– and I have diabetic neuropathy –co-morbidity“).  Nearly a third of all the listed co-morbidities that Medicare recognizes have something to do with Tuberculosis. Not a prevalent illness in the U.S. for quite a few years.  So does active cancer get you more time? Nope.  What if you “extend” your stroke (the size of your stroke enlarges) while you are an inpatient?  Nope.  How about a heart attack while you are in rehab? None of these count as co-morbidities, but you can get more time if it’s bad enough to send you out of the hospital for more than 3 nights, because if you stayed out just 2 nights then that would be 2 fewer nights available for you at rehab. If you stay out of the rehab hospital for longer than 3 nights, you get a clean slate (i.e.- a brand new “length of stay”).

Co-morbidities tend to influence a patient’s potential rehabilitation days on the order of 1 to 4 extra days.  Sound like much?  Not really considering what gets you those 1-4 days:  having a tracheostomy, being on dialysis, dysphagia, pseudomonas infections, paralyzed vocal cords, and hand full of others that regularly get counted.  Now, I’d like to believe that there is a really smart actuary out there that has taken time out from gazing at the intricacies of the stock market to delve into the time needed to recover from the 13 major illnesses that keep an inpatient rehabilitation hospital in business (a.k.a.- CMS-13).  The more likely reality is that somebody picked numbers out of a hat, and then those numbers were whittled down to what we have now by politicians that are more eager to get re-elected than they are to do the right things for the sick constituents in their districts.  If they really short the sickest patients, they won’t be around to say bad things about their mediocre health care.

I know that there are not unlimited resources.  We can’t do every procedure, run every test, and exhaust every option for every patient.  But there are so many patients that are under-served because we don’t have a way to show that they are as sick as they really are.

It’s time to update that list of things that shows how sick someone really is.  It’s time to get them the days that they deserve for fighting serious, life-threatening diseases like cancer.  Inpatient rehabilitation hospitals are the only place I know of that offers many of these recovering patients a good shot at getting home (15 hours a week or more of therapy and over 80% of all patients discharge home).  Many of the people who go to “less intensive” levels of care to recover, end up becoming long-term residents unless the patient has good family support. If it were me or my loved one, I’d want to get solid, intensive rehab if and when I needed it.  I’d want the full burden of my physical condition to be correctly reflected, and the days needed to turn that around.  I’d want to return to being a contributing member of society.  But who knows if I could do that if I wasn’t given the time to recover.


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