How to document a physical therapy discharge note for a patient with sciatica and new heart failure symptoms, who is receiving worker's compensation (WC) and has a history of cardiomyopathy with ischemia, and was stable at the start of WC, but now has orthopnea and other heart failure symptoms?

Documentation of Physical Therapy Discharge with Concurrent Heart Failure Exacerbation

Document this as a medically necessary discharge due to acute worsening of heart failure symptoms that contraindicate continued physical therapy, with clear notation that the sciatica treatment goals remain unmet and require resumption once cardiac status is stabilized. 1

Primary Documentation Framework

Reason for Discharge Section

State explicitly that discharge is due to new-onset heart failure decompensation, not treatment completion or goal achievement. 1 Your note must clearly differentiate between:

• Medical necessity discharge: Patient developed orthopnea and worsening dyspnea with activity, meeting criteria for acute heart failure event requiring cardiology evaluation 1
• Incomplete therapeutic course: Patient has not achieved functional goals for work return, specifically unable to walk community distances without antalgic gait 1

Document the temporal relationship: Patient was stable at worker's compensation initiation with only mild dyspnea with activity, but developed progressive symptoms including orthopnea during the therapy course, culminating in emergency department visits. 1

Clinical Status Documentation

Cardiovascular deterioration must be documented with specific symptoms meeting heart failure criteria: 1

• Orthopnea (new or worsened since therapy initiation)
• Dyspnea with activities previously tolerated during earlier therapy sessions
• Decreased exercise tolerance compared to baseline at therapy start
• Recent emergency department visits for heart failure symptoms
• Cardiology referral pending or in progress

Musculoskeletal status remains unchanged and requiring intervention: 1

• Persistent right sciatica with leg muscle spasms
• Antalgic gait pattern present
• Discomfort with prolonged sitting, standing, and driving
• Unable to perform work duties due to these limitations

Functional Status and Goals

Document specific unmet goals related to worker's compensation: 1

• Current status: Unable to walk community distances without antalgic gait pattern
• Work tolerance: Cannot tolerate prolonged sitting or standing required for job duties
• Goal achievement: Partial - home exercise program established but supervised therapy goals not met
• Prognosis for goal achievement: Good once cardiac status stabilized, requiring therapy resumption 1

Worker's Compensation Specific Elements

Medical Necessity Statement

Include explicit language that therapy interruption is medically necessary, not voluntary or due to non-compliance: 1

"Physical therapy is being discontinued at this time due to acute worsening of the patient's underlying heart failure with cardiomyopathy and ischemia. The patient's cardiac symptoms, including new orthopnea and dyspnea limiting activity tolerance, contraindicate continued exercise-based rehabilitation until cardiac status is optimized by cardiology. This discharge is medically necessary and not related to achievement of therapeutic goals or patient non-adherence."

Plan for Resumption

Document the expectation and plan for therapy resumption: 1

• Patient requires cardiology evaluation and cardiac optimization
• Physical therapy should resume once patient achieves cardiac stability (euvolemic state, symptom control) 1
• Continued sciatica symptoms and functional limitations necessitate further skilled intervention
• Home exercise program provided as interim measure only, not as definitive treatment 1

Critical Documentation Elements for Legal/Insurance Protection

Causation Clarity

Separate the cardiac condition from the work-related injury: 1

• Work-related condition: Right sciatica with functional limitations affecting work capacity
• Pre-existing/concurrent condition: Heart failure with cardiomyopathy and ischemia
• Interaction: Cardiac decompensation limits ability to participate in rehabilitation for work-related condition
• No suggestion that work-related injury caused or contributed to cardiac deterioration

Safety Documentation

Document that continuing therapy poses risk given cardiac status: 1, 2

• Exercise training contraindicated in decompensated heart failure 2
• Patient must be clinically stable for at least 3 weeks before exercise training 2
• Current symptoms (orthopnea, dyspnea with previously tolerated activities) indicate decompensation 1
• Risk of adverse cardiac events outweighs potential benefit of continued sciatica treatment at this time 2

Discharge Planning Language

Use specific terminology that protects against claim denial: 1

"Patient discharged from skilled physical therapy services with plan to resume upon cardiac clearance. Home exercise program provided for maintenance only. Patient requires additional skilled physical therapy intervention to achieve functional goals necessary for return to work. Discharge is temporary and medically necessary due to cardiac decompensation requiring optimization prior to resuming exercise-based rehabilitation."

Specific Note Structure

History of Present Illness Section

Document the progression from stability to decompensation: 3

• Onset: Patient was stable at worker's compensation initiation
• Baseline cardiac status: History of heart failure, cardiomyopathy with ischemia, mild dyspnea with activity
• Progression: Development of orthopnea and worsening dyspnea during therapy course
• Severity: Required emergency department visits, cardiology referral initiated
• Impact: Unable to tolerate physical therapy sessions as previously, limiting rehabilitation progress 3

Assessment Section

Include both musculoskeletal and cardiac assessments: 1

• Musculoskeletal: Persistent right sciatica, antalgic gait, muscle spasms, functional limitations for work duties
• Cardiac: Acute worsening of heart failure symptoms including orthopnea, exercise intolerance, requiring cardiology management 1
• Functional: Unable to achieve community ambulation goals, work tolerance goals unmet
• Safety: Current cardiac status contraindicates continued exercise-based rehabilitation 2

Plan Section

Provide algorithmic approach to resumption: 1

1. Patient to follow up with cardiology for heart failure optimization
2. Cardiology to provide clearance when patient achieves: 1, 2
   • Euvolemic state (no orthopnea, controlled dyspnea)
   • Clinical stability for minimum 3 weeks
   • Ability to speak without dyspnea
   • Resting heart rate <110 bpm if applicable
3. Upon cardiac clearance, patient to resume physical therapy for work-related sciatica
4. Home exercise program provided as interim measure only, not substitute for skilled therapy
5. Worker's compensation case remains open pending cardiac optimization and therapy resumption

Common Pitfalls to Avoid

Do not suggest therapy goals were met - This could result in claim closure and denial of future treatment. 1

Do not imply cardiac condition is work-related - Keep clear separation between pre-existing cardiac disease and work-related musculoskeletal injury. 1

Do not use vague language like "patient unable to continue" - Specify medical contraindication due to cardiac decompensation. 1

Do not omit the plan for resumption - Worker's compensation requires clear documentation that treatment is incomplete and will resume. 1

Do not document this as "patient discharged to home program" - This suggests treatment completion rather than medical interruption. 1