General Tips

• Document every visit/encounter.
• Adequately identify the patient or client with full name on all official documents.
• Adequately identify the PT and, if applicable, PTA with full names and appropriate designations as required by statute.
• Date and sign all entries.
• Limit use of abbreviations.
• Document legibly.
• Comply with applicable jurisdictional/regulatory requirements.
• Document at the time of the visit when possible.
• Clearly identify note types (such as progress reports, daily notes).
• Include all related communications.
• Include missed or cancelled visits.
• Demonstrate planning throughout for the conclusion of the episode of care.
• Document the referral mechanism by which physical therapist services were initiated, such as request for consultation from another provider or referral from authorized provider per Medicare or practice act—or indicate direct access as allowed by law.

Authentication

• The PT who provided the service must authenticate documentation of examination, evaluation, diagnosis, prognosis, plan of care, progress report, and discharge summary.
• The PT or, when applicable, PTA who provided the intervention must authenticate documentation in visit/encounter notes of the service.
• Medicare requires handwritten or electronic signatures; stamp signatures are unacceptable.
• A licensed PT, or when permissible by law a PTA, must authenticate documentation by PT graduates, PTA graduates, or others awaiting receipt of an unrestricted license.
• A licensed PT, or when permissible by law a PTA, must authenticate documentation by students in PT or PTA education programs.

Coding

• Have a current CPT, ICD, and HCPCS book.
• Review code narrative language.
• Select codes that accurately describe the impairments, activity limitations, or participation restrictions that you are treating.
• Use the most specific code that accurately describes the service.
• Know when a modifier is necessary and accepted by a payer.

Confidentiality

• Keep patient and client documentation in a secure area.
• Keep charts face down so the name is not displayed.
• Never leave patient and client charts unattended.
• Do not discuss patient and client cases in open or public areas.
• Enter electronic data using appropriate security and confidentiality provisions.
• Follow HIPAA requirements: http://www.cms.hhs.gov/HIPAAGenInfo/.

Evidence-Based Care

• Keep up-to-date with current research through journal articles and reviews, ArticleSearch, and PTNow.
• Include valid and reliable tests and measures as appropriate.
• Include standardized tests and measures in clinical documentation.

Medical Necessity

• Document that services are consistent with nature and severity of illness, injury, and medical needs.
• Document that services are specific, safe, and effective according to accepted medical practice.
• Document that skilled therapy is needed to maintain function or to prevent or slow its deterioration.

Progress

• Update patient or client goals regularly.
• Highlight progress toward goals.
• Clearly indicate if this is a progress report by demonstrating patient or client improvement.
• Show comparisons from previous date to current date.
• Show a focus on function.
• Reevaluate when clinically indicated.

Revisions, Changes, Adjustments

• Never modify a record after the fact without indicating that a change has been made.
• Correct charting errors or indicate other changes by drawing a single line through the original text and initialing and dating the change, or by using the appropriate mechanism for electronic documentation that clearly indicates a change without deleting the original record.

Skilled Care

• Document clinical decision making and problem-solving process.
• Indicate why you chose the interventions and why they are necessary.
• Document interventions connected to the impairment in body function and structure, activity limitation, and/or participation restriction.
• Document interventions connected to goals stated in the plan of care.
• Identify who is providing care (PT, PTA, or both), with full names and appropriate designations as required by statute.
• Document complications of comorbidities, safety issues, etc.

Terms to Avoid

• “Patient or client tolerated treatment well"
• “Continue per plan"
• “As above"
• Unknown or confusing abbreviations—use known abbreviations sparingly

Tips for Improving Documentation Efficiency

• Document at the point of care—while you are with the patient or client.
• Develop specific forms or templates in the electronic health record related to common diagnoses or specific daily note forms that include “cues" for the necessary documentation elements.
• Investigate electronic health record options for your clinic.
• Document concise information and avoid long paragraphs.
• Document only the information that is necessary for historical data, support of skilled care, and communication.
• Use as many objective tests and measures as necessary to demonstrate the impairments, activity limitations, and participation restrictions of the patient.

Top 10 Payer Complaints About Documentation (Reasons for Denials)

1. Poor legibility.
2. Incomplete documentation.
3. No documentation for date of service.
4. Too many abbreviations, and cannot understand them.
5. Does not support the billing (coding).
6. Does not demonstrate skilled care.
7. Does not support medical necessity.
8. Does not demonstrate progress.
9. Repetitious daily notes showing no change in patient status.
10. Interventions with no clarification of time, frequency, duration.