What is Defensible Documentation, and Why Does it Matter?

I think Julie Andrews was spot-on when she sang the following verse about physical therapists: “When the dog bites, when the bee stings, when you’re feeling sad, you simply remember your defensible documentation, and then you don’t feel so bad.” That is how it goes, right? No? Whoops. Looks like I mixed up some of the lyrics. But, even if defensible documentation isn’t one of your favorite things, that doesn’t make it trivial. In fact, it’s crucial for therapists to document defensibly. Because—at the very least—proper documentation justifies payment. Furthermore, as we move toward a pay-for-performance model, defensible documentation will be necessary to prove your value.  

What it Means

So, what exactly is defensible documentation? Great question. We already know how to define physical therapy documentation, and according to my friend the Oxford Dictionary online, defensibility can be defined as: “Justifiable by argument.” With that definition in mind, does your documentation stand up to scrutiny? Here are some questions you should ask yourself to find out if your notes will pass inspection (as adapted from this WebPT blog post):

• Two or three years from today, would your documentation provide enough information to recall a particular encounter and protect you against any questions or possible legal claims?
• Does your documentation support and justify your treatment and charges?
• Is your documentation clear and legible?
• Does your documentation accurately describe the patient’s course of treatment?
• Are you constantly spending time on the phone trying to appeal or explain your documentation to a reviewer?

These questions are a great place to start when evaluating your documentation practices. And if you’re unsure of how to create defensible documentation, here are some of the basics:

1. Describe the patient’s medical history and diagnosis; then, use your findings to communicate the necessity of your care.
2. Observe and document your patient’s responses to treatment.
3. Use action words to describe your treatment and the patient’s goals.
4. Avoid using abbreviations.
5. Produce legible documentation. (Hint: Document patient care electronically using an EMR.) If your payers can’t decipher your notes, your claims might be denied.
6. Incorporate standardized tests and measurements.

Need more examples?

All of these tips boil down to proving the medical necessity of your treatment. During her presentation at Ascend 2015, Deborah Alexander from the PT Compliance Group stressed that “your documented services must be at a certain level of complexity and sophistication, or show that the patient’s condition requires services that can only be delivered by a therapist.” Simply put: your defensible documentation must prove skill.

Why it Matters

So, we know that creating defensible documentation requires effort and attention to detail. But, did you know that the work you put into your documentation does more than get your claims paid? This APTA article explains that “documentation throughout the episode of care is a professional responsibility and a legal requirement. It is also a tool to help ensure safety and the provision of high-quality care and to support payment of service.” To get more granular, here are some reasons why appropriate physical therapy documentation is so crucial (as adapted from the same APTA resource):

• Your documentation acts as communication tool among providers about the patient’s care, status, and treatment outcome.
• Documentation tells others about the unique—and valuable—services you provide as a therapist.
• Defensible documentation demonstrates compliance with local, state, federal, and payer regulations.
• Third-party payers often use your documentation to determine appropriate payments.
• In legal situations, your notes act as a historic account of patient encounters.
• Finally, your documentation can be used for policy or research purposes (e.g., outcomes).

With all that in mind, if your documentation doesn’t stand up to scrutiny, you’re losing more than payments: you’re limiting the value of your profession.

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So, defensible documentation might not be all raindrops and roses, and it’s hardly whiskers on kittens. However, it is vital that you document defensibly to both get paid and prove the safety and quality of your care. So, what are you waiting for? You’ve read the post and downloaded our tips. Now it’s time to wrap yourself in some drapes, take to the metaphorical hills, and start singing about your skills through defensible documentation.