Defensible Documentation for Physical Therapy: a Guide

Defensible documentation for physical therapy protects PTs from legal issues. Learn what to include in your documentation to ensure it meets legal standards.

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Defensible Documentation for Physical Therapy: A Guide

If you don't already have a habit of regularly documenting everything in your physical therapy practice, now is the time to start. Not only must you have good records of care for every one of your patients, but the information also needs to be defensible. With quality, defensible documentation, healthcare providers will face fewer payment denials from insurers, improve patient care, and protect themselves from legal troubles.

What Is Defensible Documentation for Physical Therapy?

Defensible documentation refers to recording patient information and the progress of their treatment plan in an accurate, thorough way that complies with legal requirements. Physical therapists must be able to rely on their documentation to justify the necessity of a patient's treatment, demonstrate the proper quality of care, and defend their treatment plan in the event of a lawsuit or audit.

Defensible documentation falls under the legal compliance and risk management aspects of running your practice. Failing to keep up with documentation of a patient's status or leaving out information can have dire consequences.

Consequences of Poor Patient Care Documentation

Losing Your License

The most concerning ramification of poor documentation is the chance of losing your license. In fact, poor record keeping is such a concern that it ranks in the top ten ways to lose your PT license per an article published in the Federation of State Boards of Physical Therapy's Forum Magazine.

Well-kept records also help to address complaints against your practice if they occur. The Federation of State Boards of Physical Therapy notes that poor documentation or a lack thereof is one of the most common discoveries found during reviews of clinical documents after a complaint. If you have good documentation, you can combat complaints with evidence.

Reimbursement Issues

Another concern with improper documentation is the chance of losing money from payers denying claims on patient therapy. Your documentation must have enough information to describe the patient's needs in detail, outline how the patient has a medical necessity for physical therapy, and why they require your expert treatment.

Check with the payer for specifics of their documentation requirements. For instance, Medicare requires physical therapy documents to have the practitioner's signature on the plan of care to indicate that they reviewed and approved it. Documentation also helps to show insurers the effectiveness of treatment plans over time, should questions of continued paying arise.

Legal Consequences

Finally, if you have legal concerns in the future or must answer questions in court about a patient's care, the documentation you have on file may be your only reference. In Nursing Times, a nurse related a review process they did of an incident that concerned a pair of patients with pressure injuries.

The reviewing nurse needed to determine when the injuries happened, whether upon admission or during care. Despite a later recollection of a nurse that one of the patients had the injury upon entering the facility, the reviewer found no collaborating information paperwork created during admission.

Without proper documentation to prove that the injury existed prior to treatment, the reviewer had to conclude that the pressure injuries happened during care. Consequently, the entire staff received extra training and education on documenting everything and preventing pressure injuries in patients.

Your defensible documentation must stand up to scrutiny from the law, third-party payers, and future patient care reviews. Can your current documentation methods do all that?

Creating Defensible Documentation: 6 Tips

What should go into your documentation to ensure that you have enough information? To make your defensible documentation even more precise, use the following tips when doing paperwork:

Use Specific and Objective Language

When documenting patient information and treatment plans, be as specific as possible. For instance, instead of writing only that a patient improved their range of motion, indicate precisely how much their range improved. How many degrees did the range increase by? If looking at walking distance, how much farther could the patient travel? If working on improving patient strength, indicate the amount of weight they used each session and whether it showed an improvement from the time before.

Use common abbreviations for terms regularly used in physical therapy to save time during paperwork without sacrificing detail. Instead of writing "range of motion," shorten it to ROM to shorten the time. Using standardized abbreviations also makes the information understandable to other PTs and third-party reviewers of the patients' documentation.

Include All Relevant Information

Don't leave out any relevant information. Start with the basics of patient information. Their date of birth, medical diagnosis, contact information, insurance information, and primary care provider contact.

Next, include information on their medical history. Start with the diagnosis from their doctor. Then, outline their previous and current medications and any former PT therapy or other treatments.

Finally, include information about their current physical therapy care. Write an assessment and diagnosis of their condition. Create a written plan of treatment and objective goals. The plan should have enough detail so that any other physical therapist can replicate your treatment plan for the patient.

When writing documentation, use the correct CPT billing codes to align with third-party payer requirements. For specific information you must include, refer to the American Physical Therapy Association's guidelines for PT documentation.

Any patient documentation reviewer should clearly understand the individual's history, diagnosis, condition, treatment plan, and progress.

Document the Patient's Progress Regularly

Intake is not the only time to document patient information. Keep constant records of every treatment session, and include information if a patient canceled an appointment or refused a recommended treatment option.

Give information in the documentation about the patient's progress by using quantifiable measurements. As noted above, write detailed information, don't just indicate improvement on the paperwork. Outline exactly what measurements you took to show how much the patient improved.

Keeping track of patient progress throughout treatment allows you to make changes to the program to ensure that the patient has effective care.

Use Standard Forms and Templates

Standardized forms and templates help you to avoid missing information during documentation. Some PT practice management software allows you to create your own templates for paperwork to facilitate how your practice documents patient care. These forms help you to save time while being thorough with patient documentation.

Plus, by using templates, you keep your notes and documents clear and easy to follow. If you have handwritten notes that you import into your patient management software, make sure that the notes and other handwritten information are legible in case another person must review the documents.

Sign and Date All Documentation

Every treatment note and document you fill out and add to a patient's file needs your signature, name, license number, and date. These final steps create a timeline of care for the patient. During future reviews, the signatures show which therapists created the documents and had professional responsibility for the information provided. If an assistant also worked with the patient, their signature and information should also be on the documentation.

Signed and dated documents help to organize your patient information, ensure that data is up-to-date, and display the integrity of the file contents.

Follow HIPAA and Other Privacy Regulations

For all documentation practices, follow privacy regulations like HIPAA to protect patient medical information and personally identifying data. If you use an EMR, verify that it meets HIPAA and other privacy regulations for protecting patient data.

The HIPAA Privacy Rule outlines the specific information that falls under protection and when medical practitioners may access or share that data. Suppose you use electronic methods of storing or sharing patient information. In that case, your practice falls under the jurisdiction of the HIPAA Privacy Rule and must take steps to secure personal health information for your patients.

The Bottom Line: Mastering Defensible Documentation

Improving patient care and protecting your practice from legal concerns and payment denials start with maintaining defensible documentation for everyone. Take the above steps to ensure that all documentation you create has all the details needed.

Keep track of your patient documentation with an electronic medical record that is secure and easy to use. Try out MWTherapy yourself by requesting a demo to see how much easier creating and storing documentation can become.

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