Why a Lack of Outcomes Tracking is an EMR Dealbreaker

If you’ve been searching for a while, you probably know that a cloud-based, therapy-specific EMR solution is the way to go. You also might appreciate the importance of added benefits like built-in compliance safeguards and ICD-10 coding capabilities, billing and RCM services, and comprehensive scheduling and business reporting functionality. But, there’s one more factor you should be considering—the rehab therapy software X-factor, so to speak: outcomes tracking.

Why is outcomes tracking such a big deal? Well, at the patient level, measuring progress has always been integral to providing the best possible care. Otherwise, it’s tough to know whether the treatment you’re providing is actually working. But, with the advent of technology, PTs and OTs now have the opportunity to leverage the information they record on a larger scale—one that’ll help move the entire profession forward and ensure rehab therapists survive and, more importantly, thrive in the face of a rapidly changing healthcare payment landscape.

Now, the word “data” often carries a negative connotation, especially in the rehab therapy world. That’s because historically, payers have been the owners of that data—which means they’ve used it to justify reduced payments for physical therapy services. But now that therapists have the power to compile their own data, they have a chance to tip the scale in their favor—if they track that data in the right way, that is.

Healthcare reform initiatives are pushing all providers—rehab therapists included—to deliver higher quality care at a lower cost, all while achieving higher levels of patient satisfaction. It’s the so-called triple aim, and it’s the driving force behind the industry-wide shift to value-based payment methodologies. Soon, the outcomes your patients achieve will have a direct impact on the amount of payment you receive. And you can help make that impact a positive one by:

  • Tracking your own outcomes data—rather than leaving yourself beholden to the data payers bring to the negotiation table.
  • Using an outcomes tracking platform that will help you compile and analyze that information in a way that’s digestible and meaningful.
  • Supporting your case for higher payment rates with results that are applicable across the entire healthcare spectrum (i.e., by using outcome measurement tools that are specialty-agnostic).

Now, the term “data” might conjure up not-so-rosy visions of complex formulas and spreadsheets. In reality, though, you’re probably already halfway to the data collection finish line—and you might not even know it. Because if you use outcome measurement tools to assess patient progress, then you are, in fact, collecting data. So, why not put that information to use beyond your clinic walls?

Here’s another tidbit you might not know: there are EMR solutions out there that allow you to complete—and track the results of—outcome measurement tools directly within your documentation. These platforms even generate easy-to-read reports that tell you how your clinic is performing at the individual therapist level, at the regional level, and even at the national level. This allows you to assess and fine-tune your own clinical processes and approaches to ensure you’re always providing the best possible care. More than that, though, it allows you to prove your value to payers, referring providers, and healthcare consumers using cold, hard facts.


So, if you’re in the market for a new EMR—or if you’re simply evaluating your current one—integrated outcomes tracking capability certainly should be one of the boxes on your checklist. That way, you can be sure your EMR isn’t just your practice’s Mr./Ms. Right Now—but its forever soulmate.

Defensible Documentation Best Practices

Defensible documentation—what a buzz word (er, phrase). But it’s not just hot air; there’s a good reason why it’s so trendy. According to the APTA, creating “documentation throughout the episode of care is a professional responsibility and a legal requirement.” As a “tool to ensure safety and the provision of high-quality care,” defensible documentation serves to:

  • Communicate information about a patient’s care, status, and treatment outcome among providers.
  • Tell others about the unique—and valuable—services you provide as a therapist.
  • Demonstrate compliance with local, state, federal, and payer regulations.
  • Help third-party payers determine appropriate payments.
  • Act as a historical account of patient encounters for legal purposes.
  • Provide a resource for policy or research purposes (e.g., outcomes).

So, for your physical therapy documentation to be defensible, it must be able to justify and support your diagnosis and plan of care—and thus, your payments. But, how do you know if your documentation is thorough enough to stand up to scrutiny? Start by taking a few moments to ask yourself these questions (as adapted from this WebPT blog post):

  • Would your documentation provide enough information to recall a particular encounter—and protect you against any questions or possible legal claims—months or even years after the fact?
  • Does your documentation support and justify your diagnosis, treatment, number of visits, and charges?
  • Is your documentation clear and legible to a non-clinician?
  • Does your documentation accurately describe the patient’s course of treatment?

If you can’t answer “yes” to any of these questions—or if you frequently spend time on the phone or writing letters trying to appeal or explain your documentation to a reviewer—then you’re not only losing payments; you’re also losing your rightful place in the continuum of care.

Basically, creating defensible documentation comes down to proving the medical necessity of your treatment. As Deborah Alexander from the PT Compliance Group discussed during her presentation at Ascend 2015, “Your documented services must be at a certain level of complexity and sophistication, or show that the patient’s condition requires services that can only be delivered by a therapist.” That means you must demonstrate that you provided skilled care. To that end, the APTA offers these recommendations to improve your documentation:

  • Provide a brief assessment of the patient’s/client’s response to the intervention(s) at every visit or event.
  • Document your clinical decision-making process (like explaining why you changed the patient’s/client’s exercise program, added or discontinued a modality, or progressed a functional activity).
  • Make sure your documentation is not repetitive (i.e., don’t write the same thing every time).
  • Make sure your documentation leaves no room for doubt that only a skilled physical therapist could have provided the treatment.

Additionally, here are a few more tips for creating defensible documentation from the University of Scranton’s DTP program:

  • Avoid using abbreviations or vague phrases like “patient tolerated treatment well” or “as above.”
  • Date and sign all entries.
  • Complete progress reports, as necessary.
  • Document during the visit, whenever possible.
  • Clearly identify note types.
  • Include all related communication and missed/cancelled visits.
  • Incorporate valid and reliable —and standardized—tests and measures.
  • Produce legible documentation—or risk having your claim delayed or outright denied

One last tip: use a physical therapy EMR.

Not only can electronic medical record-keeping make sure payers don’t have to decipher your notes, but it also can keep you compliant with all defensible documentation regulations. Alerts, measures, and reminders are built into your documentation, note types are easy to identify, and you can conveniently document during (or immediately after) a visit—you know, when you can easily remember what happened and can paint an accurate picture of the patient’s condition and treatment.


Think of it this way (and bear with me): you know how castles have moats? Well, as a physical therapist, your practice is your castle, and defensible documentation is your moat. And like a moat, your documentation is more defensible when it’s full—of crucial information, that is. So, follow these tips to ensure your documentation—and your practice—is safe and sound.

Want more tips and examples of defensible documentation?
Download this chart for defensible documentation tips.

Three Reasons You’ll Wish You Used an EMR When You Get Audited

Even the word “audit” sounds awful. Think about it. Did you get goose bumps, feel a looming dark presence in the room, or shudder slightly? You’re not alone; I did too. So how do you quell that nauseous feeling in the pit of your stomach when you contemplate an audit? It’s simple: you make sure your practice is audit-proof. Not that you can ever prevent an audit from occurring, but you can certainly take steps to ensure that when one does occur, there’s no skin off your back. For example, if you were concerned about a potential IRS audit, you’d hire a tax expert to make sure your business practices and returns aligned exactly with the letter of the law. And if you’re concerned about a potential Medicare audit—which you should be—you’ll implement an EMR to make sure that your documentation is perfectly defensible. Today, let’s dive deeper into why an EMR will be your very best friend in the case of an audit.

Here are three reasons you’ll wish you used an EMR when you get audited:

1. Mistakes happen—and you’re liable for them

We all make mistakes—and most of the time they’re nothing to worry about. I mean, you can fix just about anything. Unfortunately, though, that’s not the case in an audit. Mistakes—even ones as simple as inverting numbers on a claim sheet or forgetting a step in functional limitation reporting—can cost you big time. Just one red flag can trigger a cascading audit that turns into an entire upheaval of your clinic—the effects of which can range from being a serious pain in the you-know-what and costing you valuable time that you could have spent treating patients to reimbursement denials, penalties, and fines that could add up to serious financial complications and even bankruptcy.

But it doesn’t have to be this way. With an EMR, it’s impossible to forget anything because the application has built-in alerts to prevent you from finalizing your notes until they’re picture perfect. Plus, double data entry will be a thing of the past—as will worrying about inverting numbers. You see, your EMR can seamlessly transfer everything you enter into your documentation directly onto your claim sheet. Say goodbye to human error and hello to EMR certainty.

2. “I didn’t know” is no excuse

On a scale of 1 to 10, how confident are you that you know everything there is to know about the 8-minute rule, PQRS, functional limitation reporting, and the therapy cap? Unless you answered 11—and you’ve got plenty of spare time to stay up to date on the almost minute-by-minute changes made to these Medicare regulations—there’s a huge possibility that you’re going to miss something. And Medicare doesn’t care why. They don’t care that you’re busy treating patients, running your practice, and doing the best you can—they expect you to comply, no matter what. Miss a piece of any of these requirements and there’ll be hell—I mean penalties—to pay.

Holding all that responsibility is unrealistic. Instead, put some of it on your EMR. The people working behind the scenes of your EMR will stay up on all the nit-picky little things that go into being fully Medicare compliant so you don’t have to. Now, that doesn’t mean that you can bury your head in the sand and stop paying attention to new legislation and regulations. It just means that you have some serious help. Help that—when you get audited—will be a huge lifesaver. Just make sure you choose a web-based EMR—one that’s agile enough to constantly roll out new upgrades incorporating these uber-frequent changes as they happen. At this pace, a server-based EMR will be outdated two minutes after you buy it.

3. Not being able to find or read your notes is very, very bad

Take a few minutes to survey the mess that is your office filing cabinet. Now, go back to 2007 and pull a patient record. Can you read your notes? Are they faded or penned in chicken-scratch shorthand? Could someone else—like a cranky Medicare auditor—read and understand your writing? Would they agree that your plan of care was medically necessary? Did you do a good job justifying it? Do you even still have all your records for 2007? Suppose Medicare asked you to submit information on patient Sally Joe from her visit to your clinic on March 9, 2007. How quickly could you find the information they were requesting? Is her record complete? Are you sure? Would you bet your clinic on it?

Simply writing this blog post gives me massive amounts of anxiety, so I can only imagine how anxious you’re feeling reading it. The good news is that this process can be—are you ready for it?—easy with an EMR—and that means a lot less gray hair. You see, every note you submit is complete, defensible, and—best of all—legible. Plus, you can access any record for any patient from any date of service with just a few quick keystrokes. In other words, everything is organized. And everything will be perfectly preserved for at least the minimum seven years required by law. Did you just breathe a sigh of relief? Me too.

Now, can your clinic really stand to face an audit without an EMR? I didn’t think so. It’s time to start seriously considering what an electronic medical record will do for you—and your sanity—before it’s too late.