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?

Physical Therapy Software Buyer’s Guide - Regular BannerPhysical Therapy Software Buyer’s Guide - Small Banner
  • The Devil is in the Details: How to Document Defensibly Image

    articleNov 18, 2016 | 8 min. read

    The Devil is in the Details: How to Document Defensibly

    If we polled our readers—rehab professionals like you, that is—and asked them what they love most about their jobs, we could safely bet our bank accounts that not one of our lovely PTs, OTs, or SLPs would say, “documenting defensibly.” We know; documentation is no one’s favorite. Just ask WebPTers Brian Kunich, PT, OCS, COMT, and Bradley LaFave, who surveyed their audience with that very same question during a presentation they gave at Ascend 2016 . Some …

  • Should PTs, OTs, and SLPs use the New X Modifiers? Image

    articleDec 7, 2016 | 4 min. read

    Should PTs, OTs, and SLPs use the New X Modifiers?

    In the world of rehab therapy, determining—and billing—the right codes and modifiers can be one of your biggest challenges. That’s certainly true when it comes to properly using modifier 59—and the blog posts we’ve previously written on this topic have generated a lot of reader questions. To complicate matters even more, back in January 2015, CMS rolled out four new HCPCS modifiers for healthcare practitioners to use in lieu of modifier 59—thus giving providers a way to …

  • articleNov 4, 2013 | 3 min. read

    What PQRS Could Look Like in 2014

    On July 19, 2013, the Centers for Medicare & Medicaid Services (CMS) published the 2014 Medicare Physician Fee Schedule (MPFS) Notice of Proposed Rulemaking (NPRM) in the Federal Register. According to this summary , most of the policies were open for comment until September 6, 2013 and, pending final decisions (which hopefully will occur this month), will take effect on January 1, 2014. The 605-page document contains proposals for policy changes on everything from reimbursements to the …

  • Do You Know Your Modifiers? [Quiz] Image

    articleJul 29, 2015 | 1 min. read

    Do You Know Your Modifiers? [Quiz]

    It’s a mad, mad, mad, mad Medicare world, and unfortunately, just about every regulation requires a modifier. If you apply the wrong modifier—or forget one entirely—then your clinic suffers decreased payments or flat-out denials. Even worse, if you amass enough modifier mistakes, you make your practice vulnerable to an audit. Worried you’re miserable at modifiers or want confirmation that you’re actually a modifier master? Take our 10-question quiz below to test your modifier know-how.    

  • Let’s Take “Skilled and Reasonable” to Another Level Image

    articleNov 17, 2015 | 8 min. read

    Let’s Take “Skilled and Reasonable” to Another Level

    Many WebPT Members and Blog readers already are familiar with the importance of providing documentation that satisfies the requirements set forth by payers and regulatory agencies. But, did you know there are additional important reasons for providing excellent documentation? That’s exactly what we’re going to talk about today. In the past few years, review processes for outpatient therapy documentation have become more detailed: Technical compliance is held to a more consistent standard. We’ve seen this with the …

  • The Legality of Performance-Based Employee Incentive Programs in Rehab Therapy Practices Image

    articleJan 14, 2016 | 3 min. read

    The Legality of Performance-Based Employee Incentive Programs in Rehab Therapy Practices

    The concept of pay-for-performance (PFP)—that is, the idea that an individual receives payment based on what he or she produces—seems very American to me and is certainly part of our capitalistic society. To use a sports analogy, a professional athlete who is one of the top performers in his or her sport commands higher compensation than an average or poor performer. So, why would therapy practice owners, directors, and executives not consider offering salary/compensation rates based on …

  • 5 Things You Need to Know About Medicare Audits Image

    articleJul 16, 2014 | 6 min. read

    5 Things You Need to Know About Medicare Audits

    If you treat Medicare patients, then you know all-too-well that the only thing worse than having to understand—and follow—Medicare’s thick book o’ rules is having to worry about the ever-present threat of a potential audit. After all, the national media love a good fraud story , and even if you’re fairly confident that you are doing everything right, each breaking audit headline probably plants a small seed of worry somewhere deep in your subconscious. With that in …

  • Common Questions from Our PT Billing Open Forum Image

    articleAug 18, 2018 | 34 min. read

    Common Questions from Our PT Billing Open Forum

    Last week, WebPT’s trio of billing experts—Dr. Heidi Jannenga, PT, DPT, ATC/L, WebPT President and Co-founder; John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management; and Dianne Jewell, PT, DPT, PhD, WebPT Director of Clinical Practice, Outcomes, and Education—hosted a live open forum on physical therapy billing . Before the webinar, we challenged registrants to serve up their trickiest PT billing head-scratchers—and boy, did they deliver! We received literally hundreds of questions on …

  • 2016 Rehab Therapy Year in Review Image

    articleDec 27, 2016 | 10 min. read

    2016 Rehab Therapy Year in Review

    While we’re about to close the books on 2016, we thought it would be nice—and educational—to look back on some of the therapy industry trends, advancements, and hot topics that made headlines throughout the year. Plus, most of these items will impact you and your practice in 2017 and beyond—so, as we look back, don’t forget to look forward. Okay, here we go! Clinical Trends What are those weird suction cups all about? If you, like many …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.