As physical therapists, we lead busy lives. On any given day, we may treat up to 15 patients, attend staff meetings, connect with referral sources, treat walk-ins, and somehow still find time to complete our documentation.
Unfortunately, documentation tends to be the last thought on a provider's mind, even though it's one of the most critical elements to the patient experience. Thorough documentation shows the benefit and value of physical therapy, ensures referring physicians are aligned with the plan of care, helps ensure additional visits will be authorized, and demonstrates the need for skilled care to ensure services are reimbursed.
If we do not provide detailed information and payment or authorization is denied, our patients suffer.
According to the APTA, some of the top payer reasons for denials include documentation that is incomplete, does not demonstrate skilled care, does not support medical necessity, and does not demonstrate progress.1 Documentation must be detailed. In addition to eliminating denials, detailed treatment notes prepare a therapist for the next treatment session, and allow another therapist to treat the patient should the primary provider be unavailable.
For you and your patients to benefit from detailed documentation, document at the time of service, when permissible, and complete documentation within 24 hours of a patient's visit to ensure accuracy. Below are suggestions by treatment note section on how you can make your documentation more detailed.
Reason for Referral
This section should capture the patient's history prior to evaluation with you so you may set the stage for the clinician and payer, as well as determine anything that may influence a patient's rehabilitation negatively. Include brief information on the following:
Chief complaint and injury subjective history. If the patient was referred by a physician or if the patient arrives via direct access, this too should be noted.
Prior level of function before injury. Include anything that might limit the patient from returning to this level.
Description of the patient's occupation. This offers insight into the physical demands at work. The more active the position, the more demands.
Home-setting demands. A married mother with two children may have more demands than a single young adult living alone.
Recent diagnostic tests. This will alert you on items to avoid in therapy. For example, a patient with a spinal stenosis on an X-ray may not be able to complete many lumbar extension exercises.
Aggravating and easing factors. Learn what the patient has previously done that causes or eliminates pain.
The patient's goals for physical therapy. You want to make therapy a teamwork approach and involve the patient in creating the plan of care.
Including a patient's medical history can again help you determine any factors that may influence physical therapy. This includes any comorbidities. For example, a patient with high blood pressure or diabetes may require a different treatment approach than a healthy and active teen.
Medications, surgeries, caregiver support, and risk of falls should also be noted. By listing these items, you show how you will tailor the plan of care to the patient's needs and therefore show payers and referrals the value of your services.
Being in a doctoral profession, physical therapists should take a patient's vitals, especially if a patient does not have a primary care provider, to determine any additional findings or comorbidities that could influence treatment. For example, you take a patient's blood pressure and notice hypertension that was not previously diagnosed. You document and monitor this through the next several visits.
If the patient's blood pressure was only high on the initial visit, then you may presume the patient was nervous. However, if there is no reduction in blood pressure, you may want to consider referring the patient to a PCP and note that this may hinder the patient's progression.
Again, this shows your payers and referring physicians the value of your services, as it proves you are willing to take an overall approach to the patient's treatment and individualize care directly to the patient's needs..
Standard measures such as posture, ROM, manual muscle testing, and strength should be listed in this section. Within each measurement, determine what the patient's current capabilities are, including items such as level of difficulty, degrees of extension or flexion, and symptoms that interrupt sleeping patterns.
Physical therapists are typically good about listing this information. However, it's important to push this one step further, and include a target goal for each measure and capability. For example:
Measure: Standing weight-shift (symptoms); shifting weight from one leg to the other while standing.
Current Ability: Mild difficulty. Full weight-bearing on one leg produces symptoms.
Target Ability: No difficulty. Bears full weight on one leg without symptoms.
By including target goals, you are able to show deficits, and therefore indicate the necessity for continued physical therapy.
This section should offer an overall picture of how the patient currently presents, and what your expectations are for therapy. Here, determine the patient's current level of impairment, whether or not there are any factors that might require a longer duration of therapy than normal (such as a patient with fibromyalgia who, due to pain management, will take longer to complete therapy), and the patient's likely potential to achieve your functional goals: poor, fair, good, or excellent.
If you also feel the patient would benefit from an assistive device, this is a good area to document it, as it's one of the most common sections referrals will review. You want to give the PCP as much information as possible here, so he is aligned with the plan of care.
Plan of Care
This area encompasses your functional goals and intervention strategies. It's vital that you become a master in the art of functional goal-writing, as it shows improvement objectively, without bias from other factors. Payers want to see that a patient is progressing and are more willing to properly reimburse you or authorize additional visits when this is demonstrated.
When writing a functional goal, relate it to a baseline measurement in your evaluation or other documentation. Each goal should relate to a life task that is of difficulty for the patient and is impaired due to a deficit area. Every goal should contain the following: area of the body, impairment area, impairment goal, functional activity to be performed in daily living tasks, target performance/frequency and length of time for activity, rationale as to why the activity needs to be met, and estimated timeframe to achieve desired function.2
Functional goals require detail. To simply state a goal as "patient will be able to walk in his house" doesn't offer any real information and lacks functional detail. A better example would be "patient will be able to walk 500 feet in his house to complete household tasks for 20 minutes at a time in four weeks." By creating clear outcome-based functional goals, you demonstrate why the patient requires physical therapy and, as you move through treatment, show progression.
In addition to functional goals, your plan of care section should determine your intervention strategies. This is inclusive to the entire plan of care and individualized to the patient's goals to let payers and referral sources know what treatments you believe the patient will benefit from.
All recommendations should be detailed and function-specific. Explain the proposed frequency and duration of service you believe the patient would benefit from. Being as specific as possible with a set duration and straying away from "tapering statements" will assist in obtaining the correct amount of authorized visits.
"Tapering statements" typically receive a lesser amount of visits authorized. This section also communicates the plan of care to the PCP, so detail is key to ensure alignment with the plan of care.
Here, your goal is to demonstrate why you chose to perform the selected activities that day in therapy. Although some interventions are self-explanatory, the majority are not.
By explaining the necessity and reasoning of your selections, you demonstrate strong clinical decision-making and problem-solving skills. This will set you apart from your competition and show value in your services.
When listing interactions, show your actual interaction with the patient, not what the patient completed individually in the gym. Include items such as visual, verbal, manual, or tactical cues. Education and body mechanics can also be used. As you progress throughout the plan of care, your interactions may decrease, demonstrating progress.
Treatment Time and Signature
End your note with treatment time and your signature for authentication. If you are using an electronic medical record, it is permissible to sign the record electronically. Lower direct contact time shows that the patient doesn't need as much skilled care, and is improving.
In summary, detail is key in documentation. Ensure you have a full understanding of the patient's medical history written, determine the variance between measures, current abilities and projected abilities, master the art of functional goal-writing, and offer reasoning behind your intervention strategies.
All of these items will drastically improve your documentation, show the value of your services, and help reduce denials of authorization of services and reimbursement. In addition, your patients will receive an exceptional guest experience with no interruptions from therapy and less reimbursement headaches, and become raving fans.
References are available at www.advanceweb.com/pt under the Toolbox tab.
Jeanette De Witt is clinic operator and director of Physical Therapy and Rehab Specialists of Kenosha in Kenosha, WI. Contact: firstname.lastname@example.org. Larry Briand is founder and CEO of Rehab Management Solutions in Sturtevant, WI, and owner of Physical Therapy and Rehab Specialists of Kenosha. Contact: email@example.com.