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.

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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.


4 Reasons You’ll Need an EMR for Pay-for-Performance

There’s no stopping payment reform, and no matter how tightly you cling to the fee-for-service structures you know—and, um, love?—you can’t slow the nationwide transition to a pay-for-performance environment. And it should come as no surprise that the move toward innovative payment structures goes hand-in-hand with the push for widespread adoption of innovative healthcare technologies, including electronic medical records (EMRs). But while federal initiatives—like the meaningful use program—have ushered medical professionals in other specialties into the technological age, physical therapists have, by and large, been left to fend for themselves on the EMR front. And if you’re a PT who hasn’t yet jumped on the EMR bandwagon, the pay-for-performance movement might be exactly the nudge you need to take the leap. Here’s why:

1. Outcomes tracking is crucial to proving your value as a healthcare provider.

In a pay-for-performance world, getting paid for your services hinges on your ability to objectively prove the effectiveness of those services. And that means introducing—or ramping up—outcomes data-collection efforts within your practice. The easiest way to do that? Implement an EMR with built-in outcomes tracking functionality. That way, you can easily complete outcome measurement tools directly within the patient record. If your EMR system is really on top of its game, it also will offer functionality that allows you to analyze your data in a way that produces real, meaningful insight—the kind that will go a long way toward ensuring you get the payments you deserve.

2. The more data PTs can collectively amass, the more powerful that information becomes.

For the PT industry to assert the value of physical therapy services on a grander scale—thus ensuring consistently high payment rates across the board—individual providers must coordinate their data-collection efforts. That means:

  1. using a standardized set of tools that the entire medical community—regardless of specialty—can recognize and understand, and
  2. entering data into a national—or even international—registry or repository.

After all, the larger—and more geographically diverse—the data is, the more authoritative it appears to payers and policymakers.

3. The dream of creating a national PT data registry probably won’t come to fruition without EMR integration.

The APTA has been working on creating a national data registry for a while now, and although the association’s head is definitely in the right place, the question remains: “How will the data get from individual providers to the registry?” As it stands, the answer to that question is that providers will have to manually enter their data into the registry—and as we all know, data-entry takes time. Many PTs are already so bogged down by administrative burdens that the mere thought of having to add one more item to the list is enough to outweigh the perceived benefit of having access to such a powerful data set. That’s why it’ll probably take an integrated solution—one in which patient outcomes data flows seamlessly from the EMR to the larger repository—to make the industry’s vision for a national registry actually happen.

4. Interoperability is crucial to care coordination, and web-based EMRs are crucial to interoperability.

For PTs to thrive in the coming era of pay-for-performance, they’ll need to step up and own their roles as care coordinators. But when you take on the responsibility of serving as a patient’s first point of medical contact, you also become responsible for guiding that patient’s journey through the care continuum. That means collaborating with your peers in other specialties to ensure the patient receives the best—and most appropriate—care possible, thus ensuring the best possible treatment outcome. But that kind of collaboration can’t happen—at least not in an organized, efficient manner—without patient records systems that talk to each other. Because for teams of providers to truly function as teams, each “player” must be able to access the most updated version of a patient’s medical record in real time. So, as you explore your web-based EMR options, make sure you look for a system that has interoperability on its roadmap.

There’s no way to sugar-coat it: pay-for-performance is going to have a massive impact on how—and how much—physical therapists get paid for their services. But with the right EMR by your side, the transition to value-based payment could actually benefit your practice.