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Steps to Take to Prepare for a PT Practice Audit

When you operate a physical therapy practice, there is a level of regulatory detail and scrutiny that is to be expected. Of course, the word "audit" is dreaded in every aspect of life, but for a PT practice, it should be expected and in a way, welcomed. A PT practice audit and the preparations you maintain to be ready for it keeps your practice operating properly and it assures that you will put due attention to the details of PT practice documentation.

The level of accountability that a PT practice must be prepared for means that paying attention to the details of proper documentation is not something that should be left up for grabs. Some agencies that will put your practice under scrutiny include state, county and federal government agencies, independent medical collection agencies - Recovery Audit Contractors (RACs), independent independent peer review organizations and the DOH or the Department of Health. They will need to see that you are keeping good patient records, documentation of treatment provided and billing, insurance records and other necessary documentation that is part and parcel of running a responsible physical therapy practice.

The specter of a PT practice audit can be frightening even if you have good practices in place. The best way to fight back against that anxiety is to have a checklist of steps to take to prepare for such an audit. Below are a few areas of your practice to include on that checklist.

  1. Do your own self audit of your books with a special emphasis on patient charts monthly. This is an excellent exercise to review that you have documented all aspects of patient care, including the patient's plan of care, and progress reports, functional goals, use of outcome measurement tools, and discharge summaries as well.
  2. Review if you are performing to HIPPA standards and that your efforts for getting patient consent to care forms completed is thorough. The earlier you catch any flaws in handling this aspect of patient care, the better.
  3. Part of the role you play in physical therapy for your patients is teaching them how to properly care for themselves and exercise at home. Take a look at how well your patient Home Exercise ProgramsCharts (HEPsC) are being documented: and the details of how and when patient training took place, and how well the patient is progressing week to week and the documentation supports what was given.. The greater the level of detail you have in this aspect of the patient's records, the better.
  4. Do you have a scheduled time when you work on your paperwork and documentation each week? Too often, this habit falls into the "when I get to it" category. Do not let that happen to your PT practice, because that is how your documentation gets out of order which can lead to a disaster when the time for a PT practice audit comes along. Also make this discipline part of your expectations for staff and all of the physical therapists working in your practice or practices. If they must maintain a strict schedule of maintaining their documentation, it will not become a problem for the management of your practice.

Consider moving toward PT practice management documentation automation. Electronic Medical Records should have built in auditing safeguards to take some of the worry and efforts out of the audit process. The packages that are available can reduce a lot of the stress of maintaining good practice documentation. While moving toward a full PT practice management documentation software package is a big decision, you can use other forms of computer documentation such as Excel spreadsheets and Access data bases from Microsoft to start you on that road toward automation of this important aspect of your practice. 

Article posted in Compliance

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Heidi Jannenga PT

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