Effective documentation isn't about your practice: it's part of it.
Clinical documentation of patient and client management is a professional responsibility and a legal requirement. But it's more than just a record of services provided and outcomes to support payment for services: documentation is critical to ensure that individuals receive appropriate, comprehensive, efficient, person-centered, and high-quality health care services throughout the episode of care.
The resources below are rooted in APTA Board of Directors guidelines and evidence-based best practices.
Access the main documentation elements are: initial examination and evaluation, visit, reexamination, and conclusion of episode of care summary.
There are many elements of documentation that need consideration; one of the most important is clinical setting.
Solid documentation can demonstrate that you met or exceeded the standard care and can help you mitigate your risks.
Additional Documentation Content
Oct 1, 2018 / Column
"Documenting value-based care" simply means painting a clear picture of the good things you're doing as a PT.
Mar 1, 2017 / Column
Documenting the new evaluation codes.
Aug 1, 2016 / Column
Be thorough and try to think like a payer.