5 Tips for Writing Defensible Therapy Documentation

If you had to justify the treatment you provided for a patient 3 years ago in a court of law, would your documentation stand up to the challenge?

This is how most therapists were taught to think of defensible documentation: as a way of writing to cover your backside in case you need to justify your actions in court or in an insurance claim adjustment.

But the idea of defensible documentation doesn’t have to scare you into submission. In fact, these 5 tips can help you write defensible documentation naturally and with greater confidence.

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Know Your Audience: Understand the Who of Your Therapy Documentation

Insurance agents aren’t the only ones reading your notes, and there’s more to documentation than justifying reimbursement. What you write in your therapy evaluation or daily note can also update the patient’s physician, guide other therapists and assistants, and measure the patient’s progress for you and others looking on.

Approach your documentation with the understanding that notes aren’t just for insurance, and you’ll find it’s easy to relay the patient’s progress. As in the case of storytelling, having a solid framework and knowing your audience can turn a boring message into a memorable story that’s easy to follow.

Tip 1: Relay the Patient’s Story

While it’s important in your evaluation to document the patient’s chief complaint and mechanism of injury, the patient’s story doesn’t end here! In fact, all that is just the introduction. The whole story is about the journey your patient is on—a journey to recover and achieve the goals you identified during the evaluation. And just like any good story, there will be setbacks, challenges, disappointments, achievements, and major accomplishments.

One of the talking points I’ve used in a variety of therapy settings is to ask the patient: “What things are getting easier for you to do lately?” and, “What things are still tough to do because of your injury/ailment?” Not only do their answers provide excellent content for my subjective section, but they also create a framework for my treatment session. By identifying what’s easier and what’s still a challenge, I can triangulate the movements and tasks that will best help the patient meet their goals.

Tip 2: Identify the Intent of Your Treatment

Once you have an idea of your goals for the day, you can use this information to support the treatment you select. The reader will readily follow your logic when you identify and express your intention for each treatment.

For example, if I know the patient is having difficulty maintaining their balance while dressing, I can remark on this challenge in the subjective section. I’ll then document the balance training or strength training we perform in the following objective section.

By telling a story with my notes, it’s easy for me to justify my selection of balance exercises and my choice of the CPT code Neuromuscular Re-education. And it all becomes 100% justifiable with the inclusion of an assessment statement to support the treatment.

Tip 3: Answer the question, “Why Now?”

“Why does the patient require this treatment right now?” While the answer to this question may seem obvious to you or plain to your patient, the reason for the immediacy of your treatment needs to be made explicit in your notes. The reader isn’t there to witness the conversation between you and your patient, so don’t leave out aspects of your treatment—such as its timeliness—that are pertinent to defensible documentation.

Remember, you write from a biased perspective. You’re at an advantage because, in most cases, you’ve been with your patient from the very beginning and have witnessed their progress firsthand. But if someone else were to read your notes for any particular day, they should be able to recognize the patient’s activity limitations or restrictions and see how the treatment that day was relevant.

Making a connection between the patient’s current level of function and the treatment provided is a sure way to create clear, defensible documentation.

Tip 4: Answer the question: “Why Me?”

A key element to the patient’s treatment is the one who provided it: you. So as you write your notes, ask yourself, “Why me?” Why was I necessary for this therapy session—and not a trainer at the gym? What did I contribute that justifies the skills and expertise of a therapist?”

It doesn’t have to be overt. You can simply include a comment on the patient’s performance of a task within the objective section or treatment flow sheet. These comments might identify the posture or movement faults that are contributing to the patient’s functional limitation, strength deficit, or balance issue, for example. Whatever the case, the point is that only a therapist would recognize such contributors, qualifying your statements as those of a necessary, valuable expert.

Connecting your assessment statement to the importance of addressing a patient’s movement faults is one of the best ways to answer the question “Why me?” It allows you as the therapist to showcase your expertise in the movement system in demonstrating a safe, appropriate progression of exercises and treatments.

If you need a few examples of strong, defensible assessment statements, you can find inspiration in these therapy documentation examples.

Tip 5: Support With Objective Measurements

Remember, you don’t need to wait until “progress note day” to measure your patient’s ROM, strength, balance—or anything else! In fact, if you wait until one particular day to take all the measurements, you may not get the full picture of improvement, especially if it was a “bad day” for the patient.

Besides broadening your perspective, measuring early and often can boost your note-writing. You’ll be able to point to an objective, measurable improvement instead of relying on subjective feedback or your own interpretation of a patient’s progress. That’s why some insurance companies require outcome measurement tools; it’s a tangible marker of progress.

Granted, an outcome measurement tool can only reflect one day—the day it’s completed. It can’t zoom out and show the trajectory you and your patient have made together. Therefore, try incorporating other objective measurements on different treatment days to better and more accurately track progress.

Final Thoughts on Defensible Documentation

You don’t have to be an expert writer to compose strong, defensible documentation. You simply need to think about the story you’re writing —the patient’s journey to recovery—and the role you play in that story. Whenever possible, support your documentation with objective findings and outcome measurement tools, and be sure to use the assessment section to tie everything together.

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Tim Fraticelli is a Physical Therapist, Certified Financial Planner™, and founder of PTProgress.com. He loves to teach PTs and OTs ways to save time and money in and out of the clinic, especially when it comes to therapy documentation or continuing education. Follow him on YouTube for weekly videos on ways to improve your physical and financial health.

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