Documentation sucks. We get it. We know it ain’t warm and fuzzy with rainbows and sunshine. It’s cumbersome and bang-your-head-against-a-wall frustrating. But as a physical therapist, it’s the name of the game.

According to the APTA, documentation is crucial because it:

  1. Serves as a record of patient care, including a report of the patient’s status, physical therapy management, and outcome of physical therapy intervention. It’s also a tool for the planning and provision of services and is a communication vehicle among providers.
  2. Tells others about our abilities, our unique body of knowledge, and the services we provide as PTs and PTAs.
  3. Demonstrates compliance with federal, state, payer, and local regulations.
  4. Provides a historical account of patient encounters clinics can use as evidence in potential legal situations.
  5. Demonstrates appropriate service use and reimbursement for many third-party payers.
  6. Is useful for policy or research purposes including outcomes analysis.

Documenting every treatment episode is not only a professional responsibility, but a legal requirement. Plus, it’s how you get paid when working with insurance providers and Medicare. Thus, you have to document correctly and in a manner that ensures your documentation truly justifies your services. Succinctly put: Make your documentation defensible. But what is “defensible”? As Bob Thomas, PT, states in an article on

“Sometimes, we make documentation too complicated. My opinion is that [defensible documentation] is our responsibility and obligation to tell the patient's assessment and treatment story. Review and audit of documentation consistently attempts to answer the questions: 1) Is this service medically necessary? and 2) Did it require skilled intervention? 

But what does medically necessary and skilled intervention actually mean? Medical necessity narratives must describe diagnoses and deficits, while skilled intervention narratives must demonstrate worth as a clinician. (To learn more about medically necessity and skilled intervention and see examples of them in documentation action, check out Bob Thomas’s full article on Definitely a solid read.)

Now that you understand the basic terminology, let’s talk about how to implement. According to an article entitled “The Well-Written Record” in Rehab Management, there are nine basic tenets your documentation should follow:

  1. All entries are legible.
  2. The diagnosis clearly supports justification for rehabilitative services, or the evaluation indicates specific limitations and/or functional deficits.
  3. The documented findings support the estimated frequency and duration of care.
  4. The documentation specifies plan of care and measurable goals.
  5. The documentation clearly states the treatment provided, including the amount of time spent administering specific procedures or modalities. Each treatment note substantiates the number of billed units.
  6. A record of the patient's progress, or lack thereof, documented on a regular basis justifies the need for continued skilled therapy. Additionally, the documenter records changes to the treatment plan.
  7. The name and professional designation of the person providing the service appear at the end of each entry.
  8. The documenter records patients’ or caregivers’ subjective comments throughout the course of treatment, indicating the patient's progress, unusual occurrences, new physician orders, or complaints.
  9. At discharge, the documenter includes an objective summary providing a comparison of the patient's status from the initial visit to the time of the last encounter.

The article also stresses the importance of examining your documentation to ensure it can stand up to scrutiny. Here are a handful of questions to ask:

  • "Would your documentation stand up to a patient’s claim of injury during a visit?
  • "Would your documentation provide enough information to recall events of a particular encounter 2 to 3 years after the fact, and protect you against questions and/or possible legal proceedings?
  • "Does your documentation support the patient’s need for skilled physical therapy services on a continual basis, and provide adequate justification for the number of visits, treatments rendered, and charges submitted for reimbursement?
  • "Are the terminology and abbreviations utilized in your documentation intelligible to a non-clinician rendering payment, treatment, and authorization decisions?
  • "When a third party requests a medical record, does the chart paint an accurate picture of the course of care?
  • "Do you frequently end up writing letters of appeal or spend an undue amount of time on the telephone interpreting documentation to a reviewer?"

Beyond basic principles and self-scrutiny, the APTA also has some general documentation guidelines. Here are some key ones:

  • Document every visit/encounter.
  • Documentation should include indication of a patient’s cancellations of appointments and/or refusal of treatment.
  • Make all handwritten entries in ink. Legibility is critical in clinical documentation. If people cannot read entry, they cannot understand it.
  • Enter electronic entries with appropriate security and confidentiality provisions.
  • Include adequate identification of the patient/client, the physical therapist, and/or physical therapist assistant on all documentation.
  • Include the patient's full name and identification number, if applicable
  • Date and authenticate all entries with the provider's full name and appropriate designation (license number and printed name if state law requires it).

Lots of lists, yes, but each one is jammed with so much oh-so-valuable information. As you absorb it all, let’s summarize:

Defensible documentation has and always will be important. But with the evolution of Medicare and the increasing focus on audits, it is imperative that our documentation be detailed, clear, and correct—both for ourselves as professionals and for our patients. Exemplary documentation provides a foundation for fewer treatment errors, while reducing the number of inquiries about the treatment provided. Through defensible documentation, you can minimize payment denials as well as the likelihood of any adverse legal action

As a physical therapist, you’re there for your patients, providing exceptional care. Now it’s time to tell that story. How do you tell your story through defensible documentation? What tips do you have for other therapists?

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