What is Defensible Documentation?

We get it: no one actually enjoys documentation. It can be cumbersome and time-consuming—not to mention frustrating. Unfortunately, though, for a PT, OT, or SLP, defensible documentation is a necessary evil. It’s a good thing, then, that technology can help make the entire process smoother—and that there are resources available to help you ensure your documentation meets all defensibility standards. But, what are those standards? What, exactly, is defensible documentation? In short, it’s documentation that not only clearly demonstrates the patient’s story (i.e., the results of a complete assessment and the patient’s medical history), but also proves that the services provided were medically necessary and that the patient’s condition warranted your skilled intervention. According to WebPT’s Courtney Lefferts, defensible documentation must “stand up to scrutiny.” (Looking for some optimal physical therapy documentation examples? Be sure to download our toolkit below.) With that in mind, here’s what else you need to know about defensible documentation:

It’s crucial for healthcare providers.

According to the APTA—and pretty much every other documentation subject matter expert—defensible documentation is crucial for healthcare providers. Here’s why:

• It serves as the patient’s care record—and it includes information detailing the patient’s functional status, how his or her care is being managed, and the expected treatment outcome.
• It’s a tool providers can use to plan for care provision and share important patient information with other members of the patient’s care team.
• It’s a vehicle for communicating the provider’s abilities, expertise, and services.
• It’s a way to demonstrate compliance with all regulations—federal, state, and payer.
• It serves as a historical account of interactions between the provider and the patient that the provider can present as evidence if there’s ever a legal situation.
• It proves that medically necessary services were provided—thereby making it appropriate for the provider to request reimbursement from third-party payers.
• It can provide useful data to support policy and research initiatives.

There are several main tenets of defensible documentation.

Obviously, defensible documentation is important. But, you may still be wondering what, exactly, constitutes defensible documentation. Well, according to this Rehab Management article, there are nine main tenets that defensible documentation adheres to (plus one that we’ve added):

1. It’s legible.
2. The diagnosis—or the specific limitation(s) or deficit(s) indicated within the evaluation—clearly supports the provider’s decision to provide rehabilitative services.
3. The results of the assessment and evaluation support the estimated treatment frequency and duration.
4. It includes the plan of care and measurable goals (as well as any changes to the plan or goals, along with supportive reasoning).
5. It clearly states what treatment was provided, including the time spent administering each procedure or modality. Furthermore, each treatment note justifies the number of units billed (in accordance with the 8-minute rule).
6. It includes detailed information about the patient’s progress—or lack of progress—that justifies the necessity of continued care.
7. The provider’s name and professional designation appear at the end of every entry.
8. It includes patient and caregiver comments throughout treatment (addressing things such as the patient’s progress, unusual events, changes to physician orders, and complaints).
9. At discharge, it includes an objective summary comparing the patient’s status when treatment began to his or her status at the end of treatment.
10. While this line item wasn’t included in the Rehab Management list, defensible documentation also adheres to all compliance regulations, including things like MIPS (once it goes into effect for rehab therapists).

In a presentation on the topic of defensible documentation, WebPT’s Brian Kunich, PT, OCS, COMT, and Bradley LaFave recommended that providers also integrate evidence-based practices into their documentation workflow by:

1. developing a plan of care that is well supported by research, and
2. consistently using (and documenting the results of) valid, standardized, and reliable outcomes tests and measures. (On a related note, you can also use outcomes data and supporting documentation to empower providers to deliver better patient care, fine-tune your marketing efforts, and negotiate better payment rates.)

Documenting effectively and efficiently requires balance.

According to Kunich and LaFave, it’s important to balance the patient relationship with efficient documentation: While “you don’t need to document every minute detail,” you do need to ensure that another provider “can pick up exactly where you left off.” In other words, Kunich and LaFave recommend that providers focus on “creating the story and connecting the dots.” As I wrote here, “with enough practice, proper point-of-care documentation strategies, and the right electronic documentation platform, Kunich and LaFave say you’ll never spend another night frantically trying to finish your notes as the clock strikes 10:00 PM.”

Ultimately, you should rely on your clinical expertise to clearly communicate the patient’s story—and his or her need for skilled rehab therapy intervention. To do so, Kunich and LaFave suggest providers use their documentation to:

• Account for all complicating factors;
• Include specific functional deficits;
• Explain how those deficits impact the patient’s independence and activities of daily living; and
• Communicate whether the “patient is improving or regressing—and why.”

There are self-check questions you can use to assess the defensibility of your documentation.

According the the Rehab Management article cited above, providers can evaluate their own documentation to ensure its defensibility by answering the following questions (ideally, you’d answer “yes” to every question but the last one):

• Would your documentation support your clinical decisions if a patient claimed he or he was injured during a visit?
• Could you look back at your notes from a patient visit that took place three years ago and know what happened—and why?
• Would a third party who wasn’t familiar with that patient’s treatment history be able to read the same notes and understand the course of care in its entirety?
• Does your documentation support the patient’s need for your skilled therapeutic intervention—as well as the frequency and duration of those services and the charges rendered?
• Is the language you use in your documentation clear enough for a non-clinician to understand?
• Do you often find yourself writing letters of appeal or needing to interpret your documentation to a reviewer?

Kunich and LaFave agree that scheduling regular in-house documentation audits can be a huge benefit to your practice. After all, it’s much better that you catch any problems with your notes—before Medicare does.

The APTA has some documentation pointers.

The APTA also outlined some key guidelines to help you ensure your documentation checks all the necessary boxes. For starters:

• Document every visit or encounter.
• Make a note any time a patient cancels an appointments and/or refuses treatment.
• Ensure all documentation is legible and well-organized.
• Complete electronic notes using an EMR that adheres to all security and confidentiality provisions.
• Clearly identify the patient, provider, and assistant (if applicable) on all entries.
• Be sure that the provider’s name, signature, and license number—as well as the date the documentation was completed—appears on all notes.

In summary, documenting every treatment episode in full is not only a professional responsibility, but also a legal requirement. Plus, without proper documentation, you won’t be able to collect reimbursement from third-party insurance providers and Medicare—or support yourself during a legal situation or audit. Thus, it’s imperative that all PTs, OTs, and SLPs document completely, correctly, and in such a way that any reviewer can understand that the provider’s services were justified.

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Looking for even more ways to ensure your documentation is defensible? Download your free copy of the Defensible Documentation Toolkit, which comes with ten must-know defensible documentation tips, sample notes, and a handy checklist you can use to evaluate your own documentation.