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By Harrison N. Vaughan, PT, DPT, OCS, Cert. SMT
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Defensible Documentation: A Guest Post

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In the wake of all these Medicare changes taking place lately, it is not a better time to have a great review for defensible documentation.  Medicare has made more changes in the last 8 months than last 8 years and always a good review to make sure you document correctly, so we can all get paid for what we do!  Thanks to WebPT and Heidi Jannenga for this well written piece.  Enjoy!

How Rehab Therapists Can Ensure Defensible Documentation

Documentation can be at times frustrating—or maybe that’s putting it mildly—but whether we want to admit it or not, documentation is essential to the success of our profession. It not only serves a record of patient care, but it’s also a tool for planning and providing services; communicating with providers; demonstrating compliance; and aiding evidence-based practice. Furthermore, documentation educates others about our abilities, our distinct body of knowledge, and the services we provide.
Documenting every interaction you have with your patients is not only a professional responsibility, but a legal one. Your documentation acts as a historical record you may need to rely on as evidence in potential legal situations. It’s also the only way you’ll be properly reimbursed for your services by insurance providers and Medicare. Thus, you must document correctly and in a manner that fully demonstrates why your services are appropriate and necessary to further your patient’s plan of care. In short, 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?”

Regarding Mr. Thomas’s last two questions, medical necessity narratives must describe diagnoses and deficits, while skilled intervention narratives must demonstrate worth as a clinician.
Now that we understand what defensible documentation is, let’s discuss how to ensure your own documentation can withstand scrutiny. Here’s a list I adapted from an article within Rehab Management entitled “The Well-Written Record.” Ask these questions while reviewing your notes:

  • Does my documentation stand up to a patient’s claim of injury during a visit?
  • Does my documentation provide enough information to recall events of a particular encounter two or three years after the fact and protect me against questions and/or possible legal proceedings?
  • Does my 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 I use intelligible to a non-clinician rendering payment, treatment, and authorization decisions?
  • When a third party requests a medical record, does my chart paint an accurate picture of the course of care?
  • Do I frequently end up writing letters of appeal or spend an undue amount of time on the telephone interpreting documentation to a reviewer?

In addition to asking the above questions, it’s essential you pay attention to the basics. Beyond being legible and featuring your name and professional designation, your documentation should include:

  • A diagnosis that clearly supports your decision to provide rehabilitative services.
  • Findings that support the estimated frequency and duration of care.
  • Use of functional outcome measures to objectively show patient progress throughout the episode of care.
  • A specified plan of care with measurable, function-based goals as well as extensive notes should your plan of care change.
  • An explanation of the treatments you provided, including specifics on the procedures or modalities used.
  • A record of the patient’s progress, or lack thereof, at consistent intervals.
  • Subjective patient comments that indicate progress, unusual occurrences, new physician orders, or complaints.
  • At discharge, an objective summary detailing overall progress from initial examination to discharge.

For further education on ensuring defensible documentation, check out this Defensible Documentation Quick Reference to learn the top ten tips as well as how to appropriately use abbreviations to avoid payer denials.
Defensible documentation has and always will be important. But with recent Medicare changes and increasing audits, it’s crucial that our documentation be even more detailed, clear, and correct. As a manual or orthopedic therapist, you provide exceptional patient care. But we owe it to ourselves, our profession, and our patients to tell our story of that care. How do you tell yours through defensible documentation? What tips do you have to share?
About the Author
Heidi Jannenga, PT, MPT, ATC/L
Heidi was a scholarship athlete at the University of California, Davis. Following a knee injury and subsequent successful rehabilitation, Heidi developed a passion for physical therapy. She started her 16-year physical therapy career after graduating with her Masters from the Institute of Physical Therapy in St. Augustine, Florida.
In 2008, Heidi and her husband Brad launched WebPT, the leading web-based Electronic Medical Record (EMR) and comprehensive practice management service for physical therapists. As the company’s COO, Heidi is responsible for product development/management, billing services, and customer support.
She now resides in Phoenix with Brad and their daughter Ava.

Filed under: General

2013-01-24 22:48:46



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