Chapter 16: Documentation Writing Examples and Worksheets

INTRODUCTION

Documentation is key to communication between professionals involved in the care of a patient and communication with any individuals needing access to a patient's record, including the patient. Other than a patient's or therapist's word, it is the only permanent record of the therapy or intervention a patient received and patient response to treatment. Although billing is also a written record, billing without the required documentation does not stand alone.

According to the American Physical Therapy Association (APTA),¹ documentation is:

• A planning tool for physical therapy

• Communication among providers

• Record of care provided

• Evidence of compliance with federal, state, payer, and local regulations

• An historical account of physical therapist (PT)/patient encounters that serves a legal purpose

• Vehicle for third-party payers to determine appropriateness of services

• Information that can be used for policy or research purposes, including outcome analysis

When Medicare was instituted in 1966, records were required to indicate physical therapy was rendered. The details required of services provided by PTs and physical therapist assistants (PTAs) today must, in alignment with the International Classification of Functioning, Disability, and Health model (ICF), include the following:^2–4

• Clear identification of the patient

• Referral source and mechanism (self-referral, physician, other)

• Psychosocial information, including the patient's history with identified pathology, medical diagnosis(es) and comorbidities, and physical therapy or treatment diagnoses in ICD-10⁵ codable terminology and code

• Current complaints

• Precautions and barriers

• Justification that physical therapy is medically necessary

• Be timely, objective, and descriptive

• Articulation of the skill needed

• General systems screening

• Inclusion of objective tests and measures that can be performed at the initial visit and repeated over the length of stay (LOS) with appropriate explanation of functional relevance

• Prognosis for the patient relevant to the physical therapy

• A plan of care (POC) that indicates interventions in Current Procedure Terminology (CPT)⁶ codable verbiage and clear intent

• Inclusion of time-defined objective and measurable goals, focusing on function, that reflect the problems and POC in CPT⁶ descriptive and codable verbiage identified in the initial examination and evaluation

• Treatment on a session-by-session basis, with specific skilled intervention (International Statistical Classification of Diseases [ICD]⁵ codable verbiage, skill required by the treating PT/PTA (including patient response to treatment/tolerance), rationale for change or reflection of decision-making, ensuring there is ongoing change

• Plan from visit to visit or session to session

• Description of progress over time

• On every entry: signature of the evaluating or treating PT/PTA is required, preferably legible (electronic in ...