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OBJECTIVES
Following completion of this chapter, the reader will be able to:
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Describe how manual records should be stored.
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Explain why legibility is imperative in the medical record.
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Describe the types of data found in the medical record.
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Explain how errors in the record should be corrected.
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Explain the risks involved if entries into the record are not timely.
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List why the use of abbreviations in the record is a potential problem for physical therapists.
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Explain the concept of accuracy in the record.
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Discuss objectivity in the medical record mean.
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Describe the relationship between payment and documentation.
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The management of medical records, including content and organization, should be consistent throughout the organization or consistent within each discipline. General rules in organizational policies and procedures should be well defined for the professionals maintaining the record and ensure that all individuals abide by them. Additionally, the records should be organized so that individual pieces of information are easy to locate within the record as a whole. Therefore, all records in the same facility should be organized the same way whether they are hard copy or electronic. Problems can arise, for example, when physical therapy services in a skilled nursing facility are contracted out and the documentation systems do not interact with each other. There are legal cases where critical issues in terms of medical status, changes to medications, or patient complaints were not followed up on by the next practitioner due to a delay in the documentation systems.
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Referral information (self-referred, physician-referred or physician referred/prescribed, physician extender such as a nurse practitioner [NP] or physician assistant [PA], consultation, or other) should be included in the patient’s medical record. Each state practice act provides who can refer to physical therapy and who can sign a plan of care. All states have some form of direct access to physical therapy services. If the patient comes with a written referral, that referral becomes part of the record. If referred by telephone or verbal order, the person who took the order must transcribe it, consistent with state law and facility policy. The transcription of the referral should also be followed up by a signed written referral, preferably an original rather than a fax. If the patient has direct access, that should be noted.
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As defined by the Centers for Medicare & Medicaid Services (CMS) in the Medicare Benefit Policy Manual (MBPM), Chapter 15 Section 220:1
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PHYSICIAN with respect to outpatient rehabilitation therapy services means a doctor of medicine, osteopathy (including an osteopathic practitioner), podiatric medicine, or optometry (for low vision rehabilitation only). Chiropractors and doctors of dental surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care for Medicare part B.1