It can be hard to give documentation your full attention. Your focus is rightly on your patients, and in the midst of a hectic business day, it’s easy to rely upon shorthand to complete patient notes quickly. But that push to spend less time on notes and more time on actual care could ultimately be doing yourself and your patients a disservice.
The patient notes you’re filling out might make sense within your clinic, but it’s important to remember you’re not the only audience for patient documentation. Not considering payers (or other providers) when filling out your documentation is a common mistake that can lead to billing headaches or even a potential audit for your clinic. Even worse, insufficient note-taking could result in a patient not getting the exact care they need—a lose-lose for all involved.
To ensure your SOAP notes are up to snuff, here are some useful tips on how to avoid missteps during your documentation process.
Cut out the filler words.
Locally-used terms and abbreviations may work for expediency, but they’re not doing much to communicate specifics about a patient’s treatment—or why treatment is necessary.
Why are filler words and phrases a problem? In the words of WebPT SVP of Revenue Cycle Management, John Wallace, PT, MS, “Sloppy documentation can mean sloppy treatment.” If you’re filling your notes with bits of non-specific fluff or failing to catch typos, it signals to reviewers that less effort and attention is being given to the patient care itself.
According to Wallace, some of the most common filler words or phrases found in documentation are:
- “Tolerated well”
- “Patients progressing according to plan of care”
- “Treatment as above”
Wallace also points out that automation and modern EMRs have made documentation far easier to review—gone are the days of illegible handwriting from providers. So any attempts to spam your notes with imprecise terms will stand out that much more.
Don’t include your own acronyms or lexicon.
It’s not uncommon for groups to develop their own terminology and shorthand based upon a shared understanding. It can be the same within a clinic: unique names and abbreviations developed out of convenience that mean nothing to anyone outside of your office, or at the very least are unclear.
Your own individual treatment language might be fine in the office, but terms like “deadbug” or “SAQ” should stay out of your notes. Even terms like “HEP” should be spelled out to avoid confusion. Wallace emphasizes that the goal of your treatment notes should be that another PT without any knowledge of you or your patient could replicate a semblance of your treatment step-by-step based solely upon your notes.
In this post from Evidence in Motion, WebPT Chief Clinical Officer and Co-Founder Heidi Jannenga, PT, DPT, ATC, makes the point that “(a)uditors, insurance companies, and chart reviewers all must be able to understand this information. Remember: If they aren’t seeing it
in your SOAP notes, they may not comprehend its value at all.”
Document the medical necessity of your treatment.
You don’t bill for unnecessary treatments, but your documentation might not be justifying the necessity of your treatment to payers. And if you haven’t demonstrated the medical need for a particular treatment in your documentation, you’re at a greater risk for denial when it comes to billing.
To avoid any potential documentation problems, you want to make sure you’ve documented defensibly. This means:
- Billing the correct ICD-10 codes;
- Having complete documentation of all encounters;
- Avoiding abbreviations;
- Using standard measures and testing;
- Mapping out goals and document your patients’ progress (or lack thereof), and
- Justifying your services through your evaluations.
Documentation is ultimately communication, and communication is all about clarity—and you want your notes to clearly describe to anyone reading what treatments were given and why they were medically necessary.
Include dosing information.
Specificity is important in your treatment of a patient, and it should be equally important in noting that treatment. Dosing is defined as the frequency and type of intervention, the time of the session, the length of care, and the intensity of the treatment—all important details to include in your notes. Again, those treatment notes are for reviewers as well as yourself, and you want to demonstrate to reviewers the time it took for each based upon the doses should there be questions about the units billed.
Avoid under-documenting.
While PTs should be looking to resist patient notes that read like Russian literature, they shouldn’t move too far in the other direction. Under-documentation—particularly the kind filled with cut-and-paste treatment terms—increases the chances that payers will deny treatment or reimbursement. The trick is to communicate your thoughts and intentions and all relevant correct information in as few words as possible. (Simple, right? Welcome to the world of writing; we meet Thursdays to commiserate.)
Be aware of these other common documentation mistakes.
While it may be difficult to avoid documentation errors entirely, it’s worthwhile to know what mistakes PTs are making time and again in order to guard against them in your own documentation. According to data collected by CMS under the Comprehensive Error Rate Testing (CERT) program, the most common documentation mistakes encountered with billed Medicare claims are:
- Missing certification and recertification(s)—the physician/ NPP’s dated signature(s) approving the POC
- Missing physician/NPP, therapist signature who developed the POC, and the established treatment plan date
- Missing or incomplete POC
- Missing significant POC changes certifications and recertification(s)
- Missing the required functional reporting on claims and/or medical record
- Missing total time for the timed procedures and total active treatment time
- Missing or incomplete initial evaluation
- Missing or incomplete progress reports
- Missing elements to support medical necessity
Wallace also notes that “overuse of ‘cutting and pasting’ and note ‘carry forward’ functionality is obvious to reviewers who read the entire episode of care when reviewing one or several dates of service. Your documentation must be specific to the patient and the service delivered on that day.”
Documentation may feel like a burden at times, but it’s critical to giving your patients the best care moving forward—and getting paid for that care. As Wallace says, “The documentation time is as much a part of the treatment as when you’re touching the patient. And you’re getting paid for it. So do it right.”
