defensible documentation

The Need for Defensible Documentation  

The world of health care is moving toward a paradigm of highly individualized, patient-centered care. Some of the therapy field’s main avenues of business, such as long-term care, are already experiencing an active shift toward patient-driven reimbursement. To some degree, therapists have always built an individualized program of therapy and tailored it to their patient’s needs, but with ever-changing regulation and oversight driving insurance, Medicare, and Medicaid payouts, clear and defensible documentation is more important than ever. Defensible documentation can be the difference between  a compliant, lucrative practice, and a practice that is audited and penalized from frequent regulatory mistakes that cannot be justified or otherwise explained.   

What is Defensible Documentation?  

What exactly do we mean by defensible documentation? Simply put, defensible documentation is medical charting that provides clear and compelling justification for a patient’s course of treatment. Clear physical therapy documentation helps prove to payers, insurance providers, and legal entities such as your state or CMS, that the therapy you provided was necessary and appropriate.   

Defensible documentation also helps demonstrate that your therapy practice is compliant with current health care regulations.   

Good physical therapy documentation should be able to clearly answer questions about the course of patient’s treatment and the services billed should the treatment or charges be called into question further down the road.   

What are the Hallmarks of Defensible Documentation?  

In order for documentation to be considered clear and defensible, it should always contain certain essential pieces of information. Those items include:  

  • Patient’s name and any identification number your practice uses
  • Patient’s medical history and diagnoses
  • Your plan of care for the patient
  • The name, credentials, and identification number of any therapist currently working with the patient
  • The intervention or course of treatment you administered during the visit
  • Prognosis or plans for discharge from therapy
  • Any referral to an additional provider
  • A new piece of documentation for each individual visit
  • A signature or other verification mechanism

Approach the structure of your physical therapy documentation like a continuum. The course of treatment should logically follow from the patient’s medical history and the diagnosis that they present with. The documentation should show that your recommendations come directly from the patient’s needs. Once the intervention has been put into practice and a therapist has had hands-on time with the patient, the record should indicate the patient’s performance and response to the therapy that they received. From this, a prognosis and plan of discharge can be notated.   

All notations should be clear, factual, free of any abbreviations, and above all legible. Treat your documentation as if it must hold up in a court of law or under the intense scrutiny of a state or federal auditor. You never know when it might have to.  Your practice must be able to reconcile the time spent administering each specific service or intervention to your patients with the documentation describing those services. In addition, having the right practice management solution can help your therapists avoid entering duplicate information into the EMR and billing system, thus lowering the risk of errors that can trigger an audit. A well-designed EMR is able to work seamlessly to produce billable charges from the documentation your therapists enter after each session, reducing the potential for redundant errors. 

How Can an EMR Help?  

Therapists are busy and achievement-driven people by nature. No one gets into the field with the intention of working behind a desk. Direct patient care is central to a physical therapist’s job. Documentation is often viewed as a hindrance rather than an absolute necessity. For therapy practices still stuck in a traditional documentation mindset, the results are sloppy, hand-written case notes.   

Just as a good therapist looks to put the best possible intervention in place for their patients, they should also put the best possible intervention in place for their documentation. An electronic medical record, or EMR, simplifies the burden of physical therapy notation and helps your therapists create clear, defensible documentation that is easily transferable and understood by insurance companies and auditors alike.   

Practice Pro offers EMR software that is customizable to your individual therapy practice. Our EMR software includes therapy case note templates for multiple disciplines including:

  • Physical therapy
  • Occupational therapy
  • Speech therapy
  • Pediatric therapy

Our EMR and practice management software also includes flexible scheduling applications and an industry-leading suite of business intelligence tools to help your practice improve patient outcomes. For a free, live demo please contact our representatives today.