As physical therapists, you've no doubt heard the saying, "The work is not done until all the paperwork is done." However, this often is easier said than done. While you're highly trained professionals who identify with a doctoring profession, you may at times struggle to effectively communicate your expertise.
The challenge is multiplied when you consider the components that constitute an accurate and timely record of skilled physical therapist services, as well as the audiences it reaches such as physicians, payers, patients, and consultants if/as indicated.
Effective documentation must provide details related to the therapy episode, outlining the complex factors that necessitate skilled PT services for your patient or client. This includes specific medical necessity and skilled service interventions that require the unique skills of a physical therapist or physical therapist assistant—skills that cannot be provided by other health care providers.
When documenting your services, it helps to consider two questions: Why now? And why you?