The Well-Written Record

Does your documentation stand up to scrutiny? To answer this broad question, you need to consider many specifics, such as:

• Would your documentation stand up to a patient’s claim of injury during a visit?
• Would your documentation provide enough information to recall events of a particular encounter 2 to 3 years after the fact, and protect you against questions and/or possible legal proceedings?
• Does your documentation support the patient’s need for skilled physical therapy services on a continual basis, and provide adequate justification for the number of visits, treatments rendered, and charges submitted for reimbursement?
• Are the terminology and abbreviations utilized in your documentation intelligible to a nonclinician rendering payment, treatment, and authorization decisions?
• When a third party requests a medical record, does the chart paint an accurate picture of the course of care?
• Do you frequently end up writing letters of appeal or spend an undue amount of time on the telephone interpreting documentation to a reviewer?

There have been many courses, books, guides, articles, and forms produced on documentation with the intent of assisting the therapist in what seems to be an endless task. The electronic medical record (EMR) industry also has gotten involved in the race to develop the ultimate tool to satisfy all documentation requirements and still be user friendly and practical.

PTPN has found that success in documentation does not come as the result of one particular EMR or set of forms. Form is not content. Rather, successful documentation always comes down to the author’s understanding of basic record-keeping principles and the ability to translate those principles into practice.

While some patients may require detailed ROM or muscle strength measurements, others might need only a functional assessment. Therapists decide what parameters are critical for a specific evaluation. However, they also have a responsibility to convey the rationale utilized in determining the type of evaluation selected. This also holds true for daily documentation. While there is a wide array of treatment options available and each individual therapist has a particular expertise or preferred approach, the documentation must support the treatment.

For each of the categories listed below, volumes could probably be written and probably have been. And of course, individual states, payors, PTPN, Medicare, and workers’ compensation all have unique documentation requirements that need to be satisfied for a particular patient population. But in general, if the following basic tenets are regularly followed in your documentation, compliance with chart reviews should dramatically improve.

• All entries are legible.
• Justification for rehabilitative services is clearly supported by the diagnosis, or the evaluation indicates specific limitations and/or functional deficits.
• The estimated frequency and duration of care are supported by the documented findings.
• The plan of care and measurable goals are specified.
• Treatment provided at each encounter is clearly stated to include the amount of time spent administering specific procedures or modalities. The number of billed units is substantiated by each treatment note.
• The need for continued skilled therapy intervention is justified with a record of the patient’s progress, or lack thereof, documented on a regular basis. Changes to the treatment plan are recorded.
• The name and professional designation of the person providing the service appear at the end of each entry.
• Subjective comments made by the patient or caregiver are recorded throughout the course of treatment, indicating the patient’s progress, unusual occurrences, new physician orders, or complaints.
• At discharge, there is an objective summary providing a comparison of the patient’s status from the initial visit to the time of the last encounter.

Detail and clarity are the keys to good documentation. Exemplary documentation will provide a foundation for fewer treatment errors, as well as reduce the number of inquiries about the treatment provided. Payment denials will be minimized, and the likelihood of an adverse legal action will be mitigated.

WHAT CONSTITUTES A DAILY NOTE, AND WHEN IS A WEEKLY NOTE REQUIRED?

According to the APTA’s “Defensible Documentation for Patient/Client Management,” the purpose of a daily note is to provide documentation demonstrating “the sequential implementation of the plan of care established by the physical therapist. It includes changes in patient status, a description and progression of specific interventions used that may be documented in a flow sheet format, and communication among providers. It also may include specific plans for the next visit or visits.”

Documentation is required each time a patient attends treatment. The purpose of the daily note is to provide an historical account of the services rendered both to include identification of treating personnel, and to demonstrate the need for continued skilled therapy services. Providing adequate detail on each encounter will make it easier for practices to justify the services rendered, resulting in improved reimbursement and fewer requests for supplemental information. Additionally, should questions arise later as to what did or did not transpire on a given date of service, the medical record will be used as evidence in potential legal actions. Therefore, it is important to document not only the services provided to the patient but also objective, measurable progress toward goal achievement, as well as the client’s subjective reaction to the treatment. The APTA Guide notes “while it is important to include the interventions provided, this [alone] does not demonstrate skilled care.”

The degree of sophistication and the skill level of individual reviewers asked to assess cases for proper payment or quality controls are uncertain. As such, it may be unrealistic to expect all reviewers to look at an exercise log, for example, and understand progress is being made by virtue of an increase in resistance or repetitions, or improved endurance on a particular piece of equipment. For this reason, it is imperative the daily notes clearly demonstrate objective gains in terms easily understood by trained lay persons as well as clinicians. Specifying measurable improvement on a weekly basis is vital to supporting the need for continued treatment. It should not be expected that the monthly progress note alone will suffice.

PTPN, at a minimum, requires documentation of measurable objective findings once a week. Such measures may include, but are not limited to, ROM, strength, functional status, pain level, posture, balance, gait, and required verbal cueing. Inclusion of these parameters will provide a sound foundation for justifying further care. It is recognized that in some instances, despite the best effort of the therapist, progress will not be possible. In such cases, it is expected the daily documentation will reflect the varied treatment approaches attempted to achieve a more favorable outcome, as well as the lack of measurable gains. Timely termination of treatment is anticipated in accordance with the PTPN Discharge Protocol.

Indicating weekly progress does not have to be thought of as doing a complete reevaluation. The daily notes should consistently cite elements of improvement toward goal achievement, rather than a reassessment of all deficits identified on the evaluation. For example, objective gain in some particular parameter, such as joint range, may be noted as “shoulder flex improved from 70 to 105°,” or functional gains in dressing, reaching, lifting, or walking can be documented. Remember to objectively quantify the progress achieved. A generic statement such as “ROM improved” or “pain decreased” is not adequate, nor is it objective. If progress has not been achieved, try to indicate why and state your revised plan of care such as “add mobilization” or “change the exercise routine” or indicate why changes will not be implemented at this time. This information will assist not only payors, but also staff members who might need to step in and treat the patient in your absence.

The APTA’s “Defensible Documentation for Patient/Client Management” notes a patient assessment should never say “treatment tolerated well,” as this does not provide evidence of skilled services. Rather the assessment “should reflect the therapist’s clinical decision making to include their professional assessment of the patient’s progress, response to therapy, remaining functional limitations and possible precautions. The plan of care should not simply state ‘continue,’ instead, the therapist should provide specific information related to the plan for future services including education and any possible changes in the treatment program.”

HOW SHOULD I DOCUMENT THAT I GAVE A PATIENT A HOME EXERCISE PROGRAM (HEP)?

Providing patients, families, and/or caregivers with written educational materials and home programs is an essential component of patient care. This is increasingly important in light of the continued rise in co-pays and reduction in insurance benefits. Patients rely on physical therapists to provide the best possible treatment in the shortest time frame, both in the number of visits as well as in the duration of care. Emphasis on patient education and self-responsibility is vital to successful treatment outcomes.

On any date of service where educational materials are provided to a patient, there should be a notation in the chart indicating what was discussed, along with a copy of the printed items placed in the medical record. It is a good practice to date the pages and indicate who provided the instructions. Upgrading of the HEP is anticipated at regular intervals. When additional instructions are provided, the date should be placed on the materials to identify what was given on a specific date of service. If booklets are given to the patient, and it is not feasible to copy these materials for inclusion in the chart, the nature of the handout and/or specific instructions must still be noted in the daily documentation.

In 2006, PTPN established a protocol for patient education and home programs. This protocol was sent last year to each clinic for inclusion into their PTPN QA Manual. If you are unable to locate the protocol, please contact the local PTPN office for a copy.

DO I NEED TO WRITE A DISCHARGE SUMMARY IF THE PATIENT DOES NOT RETURN FOR TREATMENT?

A discharge summary is required regardless if the patient was discharged “officially” by the therapist or the referral source, or if the patient unexpectedly failed to return for treatment. Ideally, the discharge note will include the status of the patient at the time of the last visit, provide a comparison of the initial and current findings, objectively document progress toward achievement of the stated treatment goals, and include any recommended follow-up or self-care. However, it is recognized this is not always possible.

Mitchel Kaye, PT.

In those instances when a patient self-discharges or fails to attend scheduled therapy visits with no final objective assessment, the medical record still needs to be officially closed in a timely manner. PTPN standards require a discharge to be completed, regardless of the circumstances, within 1 week of the final visit or last documented patient contact. It is a good practice to write a quick note to the referral source indicating the patient has not returned for treatment. Some practices attempt to call the patient and either try to have them return for reassessment or at least ascertain why treatment was curtailed. All attempts to contact the patient must be documented in the chart, even when only a message was left or there was no answer. The chart entry should include the date, any information obtained, and the signature of the person making the contact/entry.

In those instances in which a progress note was sent to the referral source immediately prior to the last visit, and the therapist recommended continued treatment but the patient never returned, because the physician ordered discharge or the patient failed to reschedule further visits, the chart can be closed with a note referring to the last progress report and a statement indicating the patient did not return after seeing the doctor. A separate discharge note would not be necessary as long as the above information was present.

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Mitchel Kaye, PT, is director of quality assurance for PTPN, and oversees all aspects of utilization review and case management for the network for professionals in private practice. For more information, contact .