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Documenting Functional Impairment

Module 5: Admissions, Eligibility, and Medical Necessity ยท Lesson 2 of 3

Impairment must be described in behavior and frequency, not adjectives.

Replace 'poor hygiene' with 'showers once every 10-14 days; reports being asked to leave a job interview due to appearance.' Replace 'isolative' with 'leaves apartment once weekly for groceries; no contact with peers in six months.'

Gather evidence from multiple sources: participant self-report, observation, collateral, and prior records. Note the source for each statement.

Key takeaways

  • Behavior plus frequency plus consequence equals usable evidence
  • Attribute every impairment statement to a source
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