Defensible documentation in the physical therapy world — what does this entail? A paper chart donned with purple gloves, yellow gown, and p99 respiratory mask? Or maybe a sleek EMR (electronic medical record) laced with the defensive skills of a black belt extraordinaire. Actually, it harkens to the diligent PT typing notes over lunch, after work, and before patients arrive the next morning.
What is documentation? It is the thorough note that a physical therapist writes explaining what happened during an appointment. How was the patient? What happened during therapy? Why should insurance pay the therapist? It needs to be detailed enough to stand trial in a court case yet succinct enough for a single person to document 6-16 appointments in a day.
The American Physical Therapy Association (APTA) website faithfully reminds practicing PTs why documentation is so important.
Health care consumers trust physical therapists to use their expert training to improve, maintain, restore, and enhance movement, activity, and health for optimal functioning and quality of life. While safety and quality of care is most important when caring for patients and clients, documentation throughout the episode of care is a professional responsibility and a legal requirement. It is also a tool to help ensure safety and the provision of high-quality care and to support payment of services.
The national organization also provides tips and tricks for making high-quality documentation.
First of all, these are the skeleton of a solid physical therapy note, with a little sample of what each part means.
Examination – what the patient reports (subjective, “my hip hurts right in the crease for the last 2 months”), what the PT finds using tests and measures (objective, “limited range of motion of the left hip”), and systems review (“blood pressure is 110/70 and patient is oriented to self, date, place, situation”)
Evaluation – what the PT concludes from the examination
Diagnosis – Physical therapy diagnosis is different than a medical diagnosis. For example, if a patient tore their ACL, the PT would say, “Right knee ligamentous laxity” and the MD would say, “partially torn ACL.”
Prognosis – patient’s potential ability to regain function
Plan of Care – game plan!
Defensible documentation needs some muscles to give power to the treatment. This is the evidenced-based care. Tests, interventions, and exercises that scientific study has shown to be safe and effective encompass evidenced-based care.
The ligaments and fascia that holds defensible documentation together is the risk management component. If something was not written in the documentation, it is as if it didn’t happen. Therefore, PTs need to be careful to be safe in action and documentation in every single encounter– for the patient’s sake as well as their own.
Examples of risk management in note-writing include some of the following.
Confidentiality — HIPAA. Enough said.
Incident reporting – “Mrs. J’s blood pressure dropped to 90/70 during therapy.”
Maintaining patient records — filling out the daily notes and re-evals every time, keeping copies of insurance records, patient test results (X-rays, labs, MRIs, etc), exercise prescriptions, and the all-important consent form.
Electronic health record hygiene – maintaining safe passwords, keeping other patient’s information out of sight.
Fraud, abuse, and waste – only giving care to patients who need it.
Whew! That’s a lot for a physical therapist to keep in mind while they do dozens of these documentations a week. However tedious it can be, it is important for PTs to stay true and keep their documentation strong. It needs to ricochet against the possible legal encounters. It needs to be armed with risk management and evidence-based care. And the tool that houses all of this defensible documentation is the electronic medical record (EMR). A defensible EMR will follow the guidelines suggested by the APTA to keep patients and practitioners safe in the current age of medicine.
