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“Effective patient care documentation is as important as the delivery of care itself.”1 The process of health information management by healthcare professionals presents challenges and legal responsibilities. In all documentation, physical therapy professionals must abide by professional standards, ethical codes, accreditation standards, and legal requirements in creating a permanent record of patient/client data.

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Physical therapists are responsible for creating, maintaining, and disclosing patient care medical record information as authorized by the patient or as dictated by law. Legally, the records created serve as the best evidence of patient information obtained and shared, the care rendered, the role of the healthcare provider, and whether the professional and legal standards of care were met or breached. For these reasons, physical therapists who document and collect patient health information (PHI) need to understand medical record/health information laws to ensure that they act responsibly and in compliance with applicable laws, and identify when expert legal advice is indicated.

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The significance of documenting patient care accurately, comprehensively, concisely, objectively, contemporaneously or within reasonable time, and legibly cannot be overemphasized. Content substantiates billing for reimbursement and need for present and future physical therapy/medical services. The consequences of altered, incomplete, or nonexistent records can be legally and personally catastrophic. Practical application of risk management (prevention of any type of loss—financial or otherwise) and quality care includes proper documentation. The medical record frequently is the most important document available in defending against or preventing legal actions, including but not limited to personal injury suits, criminal cases, workers' compensation actions, disability determinations, and claims of negligent or improper healthcare (medical malpractice), and is generally admissible at a trial.2 It also serves to communicate with others as to the patient's status and progress in therapy.

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The changing healthcare environment, growth of managed care organizations (MCOs) and likelihood of increasing government involvement, the widespread use of technological advances, trend towards national PHI data banks, and direct access PT permitting primary care provision, therapists are assuming new duties and greater responsibilities in roles as healthcare providers and in healthcare organization delivery systems.

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With the dominance of managed care, the decisions regarding care issues, such as visit authorization are constant. Working within stringent allowances for treatment periods will continue to be a challenge for clinicians. As a result, physical therapists need to be effective advocates for their patients to ensure appropriate approval of treatment and payment. The ability to document defensively is essential, as the contents of the medical records could negatively impact defensibility against claims or authorization for additional care.

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Documentation may not solve the dilemma of extending treatment for those who have been terminated by third-party payers, but proper recording of patient care may validate the need for more treatment while protecting against risk of liability.

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The medical record is a permanent record, whether manual or electronic, of substantive and objective evidence of patient information obtained and medical ...

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