9 Tips for Defensible Documentation

  • November 1, 2021
  • blog

If you’ve ever asked a therapist what their least favorite part of the job is, more often than not you’ll hear, without hesitation, “documentation”. If you are a therapist, then you’re probably shaking your head and saying to yourself “yes, absolutely”. Unfortunately, as we all know, documentation is one of those necessary evils that must be done, and not only that, but it must be done well enough to meet all of the defensibility standards. So, what exactly is defensible documentation? And most importantly, how do you ensure that the patient notes you are writing qualify as meeting the standards of defensible documentation?

Defensible documentation must not only include the patient’s story, but it also must provide specific enough details that indicate medical necessity and why skilled physical therapy intervention is required for your patient. If your documentation does not include these three components, then it is not considered defensible documentation and you are likely to have your insurance claims denied, especially by Medicare.

Now that we know what defensible documentation is, why is it so important? Well, according to the APTA, defensible documentation is a critical component for all healthcare providers. Here are some reasons why:

  • It serves as the patient’s record of care and includes all pertinent information relating to the patient, their diagnosis, and their treatment plan.
  • It allows the therapist to effectively communicate his/her expertise and abilities to be able to treat the patient.
  • It proves that services were medically necessary for this patient and gives justification why skilled therapy services were required.
  • It provides a record of interactions between the patient and the therapist, which if ever needed, could hold up and be called upon in a legal situation.
  • It acts as a tool that therapists can share with other healthcare providers for continued and appropriate medical care of the patient.

When writing defensible documentation, the two most important questions that must be answered, according to the APTA, are as follows:

  • Why does the patient need physical therapy services now?

When addressing why now, make sure you are considering what caused the patient’s visit, within what time frame and how the symptoms presented. Be sure to also include relevant medical and psychosocial factors that may be contributing to or influencing the patient’s presentation. Whether the patient has a new injury or is experiencing an exacerbation, the functional history should relate to their current impairments and functional limitations.

  • Why does the patient require your skilled PT services?

When documenting this component, remember that your documentation must provide proof that a patient’s diagnosis and/or impairments are complex enough that the treatment can only be safely and effectively implemented by a physical therapist or a physical therapist assistant. To do this, make sure you are including all of the education you provided and the objective tests and measures you performed and how that translates to requiring skilled care from a physical therapist.

As a therapist, every time you document, you must answer those two questions. So how do you go about making sure your documentation meets the remaining defensible documentation standards and that your claims won’t be denied by insurance companies? According to Rehab Management, there are nine main guidelines that should be routinely followed:

  1. Your documentation must be legible.
  2. The diagnosis and/or evaluation which indicates specific limitations and/or functional deficits clearly supports and justifies the need for skilled rehabilitation services.
  3. The plan of care, specifically the expected frequency and duration is supported by the objective findings from the evaluation.
  4. Your documentation includes the plan of care with specific and measurable goals.
  5. When documenting treatment for that session, it must clearly state the amount of time spent on each procedure or modality. Additionally, each treatment note must justify and accurately reflect the number of billed units for the session (specifically based on the 8-minute rule).
  6. The patient’s progress, or lack thereof, must be documented regularly to justify the need for continued skilled therapy intervention. Any changes to the plan of care and why specific changes are being made must also be included.
  7. The therapist’s name and professional designation must be included at the end of each note.
  8. Each note has a subjective portion which includes any comments made by the patient or caregiver, oftentimes relating to the patient’s progress, unusual events, new or a change  in physician orders, or additional complaints.
  9. The discharge note must include an objective summary that provides a summary of the patient’s status from the initial evaluation compared to the patient’s last session.

If your documentation continuously contains the above nine tenets, then there is less of a chance of your treatment being questioned or your reimbursement claim being denied by insurance companies. While documentation can be tedious and overwhelming, it is one of the most crucial parts of a therapist’s job as it is not only a professional responsibility, but a legal requirement as well. To ensure all of your documentation needs are met, from initial evaluations to daily notes and discharge summaries, be sure to check out HelloNote for all of your clinic’s documentation and billing needs.

References:

http://www.ptcas.org/blog.aspx?blogid=266&id=47244646009

https://integrarehabsolutions.com/defensible-documentation-for-physical-therapy/

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