Defensible Documentation: A Must for Your Practice

If the words “defensible documentation” make you want to plug in your noise-cancelling headphones, you are not alone. Healthcare providers in all sectors cringe at more documentation, but it isn’t just a bureaucratic hurdle you must clear. Proper documentation does more than meet regulatory needs, and it’s more than patient files. You already know that you need to keep complete records for each patient, but that information must also be defensible. Quality, defensible documentation will safeguard you from insurance denials and protect your patients — and your license.

The What, Why, and How of Physical Therapy Documentation

The What

Defensible documentation refers to accurately and completely recording patient information that meets legal requirements, including diagnoses, treatment, and progress. Every physical therapist (PT) must be able to rely on their documentation to justify the medical necessity and quality of their treatment in case of a lawsuit or audit.

There are some basic elements of essential quality physical therapy documentation.

1. Patient Details: Name, date of birth (DOB), contact information, insurance information, physician contact information
2. Medical Diagnosis: Specify the diagnosis for which you are treating them
3. Past Medical History: Include diagnoses for other conditions and include past PT history
4. Medication History: Include any medications they are taking
5. Physical Therapy Assessment: Include initial assessment and diagnosis
6. Physical Therapy Treatment Goals: Include a written plan that should be detailed enough for another physical therapist to follow in your absence
7. Billing CPT Codes: Make sure your diagnoses align with the CPT code you use for billing

Using the following questions to assess the defensibility of your documentation is a good place to start for most rehab therapists.

• Would your documentation support your clinical decisions if a patient claimed they were injured during a visit?
• Could you review your notes from a patient visit three years ago and understand what happened and why?
• Would a third party unfamiliar with that patient’s treatment history be able to read the same notes and understand the course of care?
• Does your documentation support the patient’s need for your skilled therapeutic intervention, the frequency and duration of those services, and the charges rendered?
• Is the language you use in your documentation clear enough for a non-clinician to understand?
• Do you often find yourself writing letters of appeal or needing to interpret your documentation to a reviewer?

In addition, several authors suggest using evidence-based practices in your workflows by developing a plan supported by research and using valid, standardized outcomes tests and measures.

In summary, your documentation should account for complicating factors, detail specific functional deficits, and explain how these deficits impact the patient’s quality of life and daily functioning. Be sure to document progress or lack thereof and document why this is occurring. This is helpful from a defensibility standpoint, but also to keep you on top of your own treatment, should

you have a patient return for more treatment or for an additional injury later on. Good quality documentation has many benefits.

The Why

Everyone knows documentation is essential to any medical practice, but it can be easy to forget the ramifications of poor patient care documentation sometimes.

Losing Your License

This one alone should give you pause. In a list of the top ten ways to lose your physical therapy license, poor documentation ranks among the other more obvious ones, such as outright fraud and sexual harassment.

Well-kept records are not just for keeping your license in good standing; they also address complaints against your practice if they occur. The Federation of States Boards of Physical Therapy notes that poor documentation is among the most common discoveries during reviews following a complaint. Having good documentation can help combat complaints when the evidence is documented.

Reimbursement Issues

It isn’t just your license; your income is also at stake. Your documentation must have enough information to describe the patient’s needs in detail, the estimated time medically necessary for physical therapy, and why they need your treatment.

Each payer will have specifics for the documentation they require. For example, Medicare requires physical therapy documents with the practitioner’s signature on the care plan to indicate that it has been reviewed and approved. Thorough documentation can also demonstrate to insurers the effectiveness of the treatment plan over time if questions of continued payment arise.

Legal Consequences

If losing your license or payment is not enough, then the legal ramifications should be enough of a reminder when documentation feels difficult. Should you have legal concerns in the future or have to answer questions in court about a particular patient’s care, your documentation may be your only reference.

An example from the Nursing Times illustrates how the review process concerns a patient with pressure injuries. During the review, the examiner needed to know when the injuries occurred—were they present upon admission, or did they happen during care? One nurse later recalled that the patient had the injury upon admission, but there was no documentation.

Without the necessary documentation, the reviewer had to conclude that the pressure injuries occurred during care. As a result, the entire staff received additional training and education on documenting everything and preventing patient pressure injuries. This is true for rehab therapy, too, and it’s always worth staying on top of your documentation should you find yourself in a similar situation.

Your defensible documentation must withstand scrutiny from reviewers, third-party payers, and legal representatives. Take the time to ensure that it can do just that.

The How

Six Tips for Creating Defensible Documentation

What should you put in your documentation to ensure you meet all the requirements? To make your documentation more precise, here are six tips to follow.

Use Specific and Objective Language

When documenting patient information and plans, be as specific as possible. Instead of merely writing that the patient improved their range of motion, indicate how much it improved – how many degrees of range? If evaluating walking distance, note how much further the patient could walk. For strength, state the weight used in each session to demonstrate improvement. 

Use common abbreviations for terms regularly used in physical therapy to save time – without sacrificing detail. Standardized abbreviations will make your notes understandable to other physical therapists and reviewers.

Include All Relevant Information

While this seems obvious, numerous examples of documentation need to include this essential information. Start with the basics: DOB, medical diagnosis, contact information, insurance information, and primary care provider. 

Then, add their medical history, beginning with the diagnosis from their primary provider. Outline previous and current medications and include any PT therapy. As above, include an assessment, diagnosis, and treatment plan with objective goals. 

The plan should be detailed enough to be understandable by any other physical therapist. To meet third-party payer requirements, align the correct CPT billing codes with your documentation. The American Physical Therapy Association has guidelines for PT documentation.

Document Patient Progress Routinely

Keep accurate records of each treatment session, including information when a patient cancels an appointment or refuses a particular treatment. As with the advice about specificity, use quantifiable measurements to indicate improvement or lack of progress. Tracking patient progress throughout the treatment will allow you to make necessary changes and demonstrate the effectiveness of your care.

Use Standard Forms and Templates

Depending on your electronic health record (EMR), you may be able to design your templates, or they may have some already installed for your use. These will help you keep all the pertinent information where you need it. In addition, the use of templates makes your notes easy to follow.

Sign and Date

Every note you add to your patient’s file needs your signature, name, date, and license number. This helps maintain a timeline for your patient’s care. Again, all of this information will be necessary during a review. If you have an assistant, their information should be included as well.

Follow HIPAA and Other Privacy Regulations

By now, you should understand the need to adhere to HIPAA. Your EMR also needs to follow HIPAA policies. The HIPAA Privacy Rule outlines the information that falls under their jurisdiction and when and how you may share patient information.

Physical Therapy Documentation: The Rest of the Details     

Most documentation follows a standard format or template, but certain situations require additional details. Here are some cases where your documentation needs adaptation.

Minors and Pediatrics

With minors, these details also need to be included in your documentation:

• Written parental consent
• Details about the presence of the parent/guardian if present during treatment
• Treatment plans or assessments modified due to patient age or development

Cognitive Impairments

If your patient has cognitive impairments, include the following in your documentation:

• Description of patient’s expressed understanding of their condition and plan
• Modifications to communication, if needed (such as visual aids)
• Caregiver presence

Home-Based Therapy

When traveling to a patient’s home for therapy, there are a few other things to include. Additional details for your notes:

• Home environment description, including any safety hazards
• Necessary modifications to the treatment plan due to the home environment
• Communication details with caregivers or involved family members

Complex or High-Risk Cases

Cases with multiple diagnoses or procedures require more documentation, such as:

• Justification for treatment selection
• Detailed rationale for every treatment or intervention
• Careful monitoring with detailed progress notes

Medicare and Medicaid Billing

There is no surprise here: there are specific documentation requirements for both Medicare and Medicaid. Verify that you understand the guidelines for both, including:

• Medical necessity for your treatment plan
• Detailed descriptions of each intervention as well as its duration
• Patient functional limitations and improvements

Physical Therapy Documentation: It Matters to Everyone

You already have the skills and knowledge to document successfully. Using the right tips and techniques, you can increase productivity, enhance profitability, and improve patient performance. Effective documentation requires ongoing attention to detail and a commitment to accuracy. As the field of physical therapy evolves, so will the documentation standards. Staying informed of these changes and adapting to your practice will contribute to improved communication and outcomes.