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Eli's Rehab Report

Documentation:

Why Is Appropriate Documentation Crucial For Therapists?

Get help from APTA.

If you have been wondering why there is a spotlight on documentation these days, the American Physical Therapy Association’s (APTA’s) Center for Integrity in Practice’s has some answers: “

  • It serves as a record of patient or client care, including a report of the individual’s status, physical therapist management, and outcome of physical therapist intervention.
  • It is a tool for the planning and provision of services and is a communication vehicle among providers.
  • It tells others about the physical therapist’s abilities, unique body of knowledge, and services provided.
  • It demonstrates compliance with federal, state, payer, and local regulations.
  • It provides an historical account of patient and client encounters that can be used as evidence in potential legal situations.
  • It may be used to demonstrate appropriate service utilization and payment for many payers.”

Even if current and proposed documentation requirements seem onerous, compliance is vital as Medicare as well as private payers have fairly rigorous standards for clinical documentation.

Keep in mind: If you must make a correction or an addendum or a late entry, you must sign clearly and date it on the date the correction or addendum or late entry is made. Otherwise, you could be heading for fraud charges and face action under fraud and abuse laws.

For more on this, check out http://integrity.apta.org/Documentation/

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