All physical therapy and rehabilitation services certainly need to be documented, and this can greatly benefit the aim of financial management. The leading cause of service payment errors arises from inadequate documentation in the medical records. Well maintained service records should include measurable long term treatment goals, treatment duration, patients’ diagnoses and the proposed type of therapy and treatment. The anticipated plan of discharge and frequency of the services required to achieve each goal should also be clearly indicated. Other issues that result from inadequate documentation are such as:
• Missing signature for therapists certification
• Illegible or missing signature on the plan of care
• Missing signature on the flow sheet
Physical therapy documentation tips and requirements
Physical therapists are encouraged to go through the following documentation tips for guaranteeing complete and accurate medical records.
Content of plan of care
A good plan of care contains the following information at minimum:
• The type of diagnoses
• Long term treatment goals. These should be for the entire duration of care and not only for the service offered under a plan for one interval of care.
• Therapy type, for instance physical therapy, speech therapy, occupational therapy and so forth. Where appropriate, a description of the specific type of treatment need to be detailed. The plan must specify the kind of the therapy being provided by the therapist.
• The number of times a specific type of treatment will be provided. If this number is not specified, then the treatment session per day is assumed.
• The frequency of therapy services. These are the number of times in a specific period the type of treatment is being provided. If not specified, then one session of treatment is assumed. The plan of care has to be consistent with the related evaluation.
• The duration of treatment. This details the number of weeks of treatment sessions for the plan of care.
• Documentation of any change in the plan of care when done, date modified, including how it was modified and why the previous goals could not be met or weren’t met.
A plan of care should strive to show all the happening during the entire treatment duration, balancing the achievable outcome with appropriate resources.
The purpose of these notes is to show a detailed record of all treatment sessions and the skilled interventions being provided. These also show a record of time for the services provided so as to justify the use of billing codes on the claim. Remember proper documentation is required for each treatment session for billing purposes. Documentation of each treatment session has to include the following elements:
• Treatment date
• The provided therapy type and the billed service
• The total claimable treatment minutes
• A professional identification and signature of a qualified therapist who provided the service, including a list of each person that contributed to the treatment.
All in all, documentation for the offered service must be completed by a qualified physical therapist or clinician who furnished the service. The therapist should also document his clinical judgment in assignment of the correct severity modifiers.