Get a straight answer to a documentation question.

Answer:
A grade of 3/5 means the muscle moves the joint through its full available range against gravity, with no resistance added. 3+/5 means that same full range against gravity, plus the muscle tolerates minimal resistance at the end of the range before it gives way. 4/5 holds against moderate resistance through the range, and 5/5 holds against maximal resistance in a position where you cannot break the contraction.

The plus and minus modifiers are the least standardized part of the scale, and Daniels and Worthingham's grading does not include them at all. Facilities differ on whether they use them, on whether 3+ means minimal resistance or full range achieved with difficulty, and on where in the range the resistance is applied. Document the grade alongside what you tested and saw, for example "R knee extension 3+/5, seated, full available range against gravity, gave way to minimal resistance at terminal extension." A reviewer can follow that whichever version of the scale their facility uses. A bare 3+/5 leaves them guessing.

Answer:
Minimal assistance means you gave physical assistance and the patient did roughly 75 percent or more of the work. Contact guard assist means your hands were on the patient and no assistance was given: you were positioned to catch a loss of balance that never required you to act. The dividing line is whether force went from you into the patient. If you steadied them at any point in the task, that portion was min assist.

Both terms sit inside a scale that facilities and payers define differently, and some settings put close supervision or standby assist between contact guard and supervision. Medicare's Section GG does not separate them at all: supervision, touching assistance and contact guard assistance are scored as one code. Document the level alongside what your hands were doing and why, for example "CGA for 150 ft ambulation with RW, hands at gait belt, no assist required, one anticipated LOB corrected by patient independently." That description holds up in front of a reviewer working from a different scale than yours.

Answer:
Modified independent, written Mod I, means the patient completes the task safely on their own, with an assistive device, adaptive equipment, more than a reasonable amount of time, or a standing safety consideration. Nobody has to be present. Supervision means the patient completes the task with no physical assistance, and a person still has to be there: to cue, to watch for a safety error, or to be available if something goes wrong. The presence of that person is the whole difference between the two.

Payers read these two very differently, because Mod I usually signals a patient who is safe to be left alone and supervision usually signals one who is not. Facilities also vary on whether intermittent verbal cueing counts as supervision or as min guard. Document the level alongside the reason for it, for example "Supervision for tub transfer, no physical assist provided, intermittent verbal cues for sequencing and hand placement, one safety error self-corrected." That tells a reviewer why the person in the room was needed.

Answer:
Documentation reads as skilled when it shows the clinical reasoning only a therapist could supply: what you assessed, what you changed because of it, and why. "Patient ambulated 150 feet with rolling walker" records an activity that an aide could have supervised. "Assessed gait and identified decreased right step length with trunk flexion, provided verbal and tactile cues for upright posture and heel strike, patient ambulated 150 feet with rolling walker with improved step symmetry by end of session" records the same distance and shows the skill applied to it.

The specific wording a payer wants varies by payer and by setting, and some facilities keep an internal list of phrases their reviewers flag. The version that travels is to document the observation that drove the decision, the decision itself, and the response to it, for example "noted compensatory trunk lean over left stance limb, provided tactile cueing for weight shift through left LE, lean reduced over the final 50 feet." A verb like assessed, instructed, modified, or progressed earns its place when the sentence around it names the specific thing that was assessed or modified. On its own it is a label.

Answer:
Medical necessity is carried by three things in the note: the deficit stated in functional terms, the skilled service that addresses it, and the measurable response, or the specific reason there has not been one. "Decreased standing tolerance" is a deficit. "Decreased standing tolerance to 4 minutes, limiting ability to prepare a meal at the counter" is a deficit tied to a function a payer recognizes, and the intervention that follows it reads as necessary.

What each payer expects to see varies, and wording that satisfies one commercial plan is denied by another. Medicare Part A, Part B, and managed plans differ in how much detail they want and how often they want it restated. Document the functional deficit, the skilled intervention, and the response in every note, and where a payer has published its own language for your setting, use theirs. Confirm anything that affects coverage against your own payer and facility policy.

Answer:
A usable goal names who does what, under what conditions, to what measurable level, by when. "Patient will ambulate 150 feet with rolling walker and supervision on level indoor surfaces in 4 weeks" has all of them. The measure is the part most often left out, and a goal without one cannot be shown as met or unmet at reassessment. Long term goals state the functional outcome. Short term goals state the steps that get there, and each one should move a single variable so you can tell which step stalled.

Goal formats vary by facility and by setting, and some payers require goals tied to a specific functional activity or to a standardized measure. Write the goal so the observation that proves it is the observation you already record each session, for example if the goal names 150 feet with supervision, the daily note needs distance and assist level in it. A goal measured in something you never document is a goal you cannot close.

Answer:
Maximal assistance means the patient performs a minority of the effort and you supply the rest. The percentages come from the FIM scale, which puts max assist at 25 to 49 percent patient effort, moderate assist at 50 to 74 percent, minimal assist at 75 percent or more, and total assistance below 25 percent. So 25 percent is the bottom of the max assist band, and a patient doing 40 percent of the work is still max assist. The percentages are an estimate of effort and were never intended to be measured, so treat them as a shared vocabulary for how much of the work was yours.

This is one of the least consistent parts of assist level documentation, and the definition varies by facility and by setting. Some facilities use the FIM percentages, some define the levels by how many people the task takes, and Medicare's Section GG uses neither: it scores on whether the helper does more or less than half the effort, and no percentage appears in it. Document the level alongside what you actually did, for example "Max assist x1 for sit to stand from low surface, therapist provided anterior weight shift and knee block, patient initiated and assisted with push-off from armrests." That is readable under any of those scales.

Answer:
Document what was offered, what the patient said or did, what you did about it, and what happens next. A note that says only "patient refused" leaves a missed session on the record with no clinical content behind it. A usable version names the intervention offered, the reason the patient gave if they gave one, the education you provided about the consequence, whether you offered an alternative or another time, and who you notified. A refusal is a clinical event and the note should read like one.

Facilities differ on whether a refusal is billable, whether it needs a separate communication or incident note, and who has to be told. Payers differ on how many refusals they will accept before they question whether the patient can participate in therapy at all. Document the refusal alongside the observation behind it, for example "Pt declined OT session, reported 8/10 R hip pain and had not received scheduled analgesic, educated on relationship between session participation and discharge goals, notified RN, session rescheduled for 1400." That record explains the gap in the plan of care.

Answer:
Objective covers what you measured or directly observed, written so another clinician could reproduce it. Range of motion in degrees, manual muscle test grades, distance ambulated, assist level, repetitions, time held, vital signs, standardized test scores, and specific descriptions of movement quality all belong there. "Patient tolerated session well" and "patient did great with transfers" are impressions. They belong in the assessment, with the reasoning that supports them.

Patient report stays in the subjective section even when it contains a number, so a pain rating the patient gave you is subjective and a goniometric measurement is objective. Facilities differ on where to put the things that sit between the two, such as an observed grimace or a caregiver's report. Document the measurement alongside the conditions it was taken under: the position, the surface, the device, and whether it was the first repetition or the fifth. The same number under different conditions is a different finding.