There is no question that maintaining a high level of quality in the documentation of treatment for patients at a physical therapy clinic is a top priority. It is easy to develop a love/hate relationship with the documentation that is both prudent and a requirement to be in compliance legally and to expect reimbursement from Medicare or a patient’s insurance company.

As is true in any discipline, it is a smart idea to go back to the basics and this is true when it comes to PT documentation. It is important to not just know how we do what we do but why we do it. It is also a good exercise to go back to basics about PT practice documentation when orienting new staff members so that they are well grounded in this essential part of running any physical therapy clinic.

At the very core of any program to provide physical therapy for a patient in need are two questions that are asked and those questions will drive the treatment program and the results. It may not be surprising that neither of these two core questions have to do with reimbursement or payment or eligibility of the patient for insurance. The two questions are….

• Are the types of therapy you will provide medically necessary for the patient?
• Are the injuries or problems of the patient such that your skilled intervention is necessary for recovery?

The two key phrases that will drive the rest of the process of documentation and the development of treatment are “medical necessity” and “skilled intervention.”

To establish medical necessity, there needs to exist in the PT practice documentation about the patient sufficient information about the diagnosis and details about the nature of the problem to be corrected by therapy. It is especially important for a patient starting treatment to bring together all pertinent documentation from the referring physician, including the diagnosis and recommended physical therapy treatment. You should also have complete documentation about any limitations the patient is under, medications being taken, and other special considerations.

To document that the skilled intervention of a physical therapist is needed, the patient must come to you from a medical professional who has sent the patient to you for care. The required treatment must be of a level of care that the care of a PT assistant or self care will not be adequate to provide a solution to the patient’s problem. That means that specific types of treatment must be spelled out prior to the start of treatment that can be demonstrated to require the specialized skills, training and sophistication of a physical therapist.

Once these two requirements for treatment have been defined and detailed in the patient profile, concrete goals for the patient that show that the treatment will take the client from the current state of injury to an adequate level of recovery are added to the patient’s PT documentation. From that time forward, each session with the patient will be documented within the context of those initial evaluations and progress reports must substantially demonstrate progress toward the goals that are based on concrete evaluations and testing.

This level of careful definition of the nature of the treatment to be provided, how the therapist made the decisions he or she made along the way, and how each step of the treatment took the patient steadily along a prescribed path to recovery will pay off in the end. Of course, there are complications and setbacks, but a firm foundation in the basics when setting up a PT patient’s therapy documentation has allowances to discuss those difficulties and demonstrate a plan for dealing with the problem that will stay within an allowed and paid-for physical therapy plan.

“I now have more family time because of WebPT. I have always taken my work home with me but now it takes me half the time and I have complete access to all of my patient records at my finger tips from home as well. “ Ben Freeman, Owner/PT, Peak Energy Performance Therapy