The Devil is in the Details: How to Document Defensibly

If we polled our readers—rehab professionals like you, that is—and asked them what they love most about their jobs, we could safely bet our bank accounts that not one of our lovely PTs, OTs, or SLPs would say, “documenting defensibly.” We know; documentation is no one’s favorite. Just ask WebPTers Brian Kunich, PT, OCS, COMT, and Bradley LaFave, who surveyed their audience with that very same question during a presentation they gave at Ascend 2016. Some of the answers they received included “helping others,” “improving people’s quality of life,” “restoring function,” “meeting and interacting with different people,” and “making a difference.” No one claimed to enjoy charting—at least not until Kunich and LaFave asked what therapists liked least. While documentation may not be the most well-liked aspect of a rehab therapist’s job, it is a crucial one—for you and your patients. And these days, relying on therapy documentation templates—especially paper ones—is risky business. With that in mind, here’s everything you need to know about this necessary evil:

What is defensible documentation?

According to Rehab Management, defensible documentation adheres to these nine basic tenets (which we originally discussed in this blog post):

1. It’s legible.
2. The diagnosis clearly supports the decision to provide rehabilitative services—or, the evaluation indicates specific limitation or deficits.
3. It supports the estimated treatment frequency and duration.  
4. It includes the plan of care and measurable goals (as well as any changes to the plan or goals, along with supportive reasoning).
5. It clearly states what treatment was provided, including the time spent administering each procedure or modality. Furthermore, each treatment note justifies the number of units billed (in accordance with the 8-minute rule).
6. It includes detailed information about the patient’s progress—or lack of progress—that justifies the necessity of continuing care.
7. The provider’s name and professional designation appear at the end of every entry.
8. It includes patient and caregiver comments throughout treatment (addressing things such as the patient’s progress, unusual events, changes to physician’s orders, and complaints).
9. At discharge, it includes an objective summary comparing the patient’s status when treatment began to his or her status at the end of treatment.

Kunich and LaFave also said providers should integrate evidence-based practices into their clinical documentation—specifically, by:

1. selecting a plan of care that is supported by research, and
2. consistently using and documenting valid, standardized, and reliable outcomes tests and measures. (You can also use solid outcomes data and supporting documentation to empower your patients, market your clinic, and negotiate better payer rates. How’s that for a win-win-win?)

In this Advance article, Bob Thomas, PT, MSPT, explains that defensible documentation is the result of a therapist’s “responsibility and obligation to tell the patient’s assessment and treatment story.” In his experience, documentation reviews and audits usually attempt to answer two questions:

1. “Is this service medically necessary?
2. “Did it require skilled intervention?” 

According to WebPT’s Courtney Lefferts, your documentation must “stand up to scrutiny.”  

Why does defensible documentation matter?

Defensible documentation supports your clinical decision-making—and ensures you’re adhering to your standards of practice. It’s essentially a historical record of your patients’ conditions and progress as well as your treatment interventions. According to Kunich and LaFave, defensible documentation serves three main purposes:

1. Communication

Accurate, comprehensive, and timely documentation serves to inform the patient’s healthcare team about his or her progress. As a result, it allows for continuity of care, which is incredibly important for a patient's’ overall progress as well as for provider efficiency.

2. Payment Justification

Defensible documentation supports a provider's decision to not only provide specific services, but also bill for them. Documentation strength can mean the difference between receiving a claim acceptance and a denial, and we all know how detrimental recurring payment denials can be. That’s no bueno for your bottom line.

3. Legal Protection/Risk Mitigation

Because it contains a complete account of each patient encounter, defensible documentation can help protect a provider in the case of a lawsuit or audit. It can essentially back up your oral account of the events that took place on a particular date of service as well as demonstrate that you met—or even exceeded—the standard of care. Without defensible documentation, “there is no evidence to support your recollection of events, and an attorney can call it into question,” Kunich and LaFave said.

How do I ensure my documentation is defensible?

According to Kunich and LaFave, the goal is to balance the patient relationship with efficient documentation. “You don’t need to document every minute detail,” they said. But if you decide to sail off into the sunset tomorrow, another provider in “the clinic should be able to pick up exactly where you left off.” In other words, you should spend your energy “creating the story and connecting the dots.” With enough practice, proper point-of-care documentation strategies, and the right electronic documentation platform, Kunich and LaFave say you’ll never spend another night frantically trying to finish your notes as the clock strikes 10:00 PM. Here’s where you should focus your energy:

Communicate the patient’s story—and be clear about the need for skilled physical therapy services.

Using your clinical knowledge, paint a clear and comprehensive picture of the patient. That means:

• accounting for all complicating factors,
• including specific functional deficits, and
• explaining how those deficits impact the patient's independence and activities of daily living.

Kunich and LaFave also recommend that you clearly communicate whether the “patient is improving or regressing—and why.” Ultimately, you want to be sure that no matter who reads your documentation, it provides the same understanding of the patient’s condition, goals, your intervention (as well as why you decided to provide that intervention), and the patient’s progress towards his or her goals. It should be evident that the patient required the services of a skilled physical therapist—and no one else. Kunich and LaFave also recommend making sure that your documentation is not repetitive. In other words, don’t copy and paste the same phrase or paragraph on each note. Instead, provide relevant details that arise during each patient visit. Remember, these are legal documents that must support your clinical decisions.

Create an audit plan.

According to Kunich and LaFave, scheduling regular in-house documentation audits can be incredibly beneficial. When you do an internal review, ask yourself the following questions about your documentation as it stands now (originally adapted from the same Rehab Management article and the same blog post):

• Would your documentation support your treatment decisions if a patient claimed he or she was injured during a visit?
• Could you review your notes from a patient visit that took place two or three years ago and know what happened?
• Would a third party be able to read the same notes and understand the course of care in its entirety?
• Does your documentation support the patient’s need for skilled therapy—either on an ongoing basis or for the number of visits, services, and charges rendered?
• Are the phrases and abbreviations you use in your documentation clear enough for a non-clinician to understand the events that you describe?
• Do you often find yourself writing letters of appeal or interpreting documentation to a reviewer?

How does compliance fit into the picture?

While compliance was not included in the original Rehab Management list, Kunich and LaFave both note that defensible documentation must also adhere to all compliance regulations, including things like functional limitation reporting (FLR) and PQRS (or MIPS when it goes into effect for therapists). To learn more about FLR, PQRS, and MIPS, check out this guide, this guide, and this blog, respectively.

Phew. That was a lot, right? It’s a good thing Kunich and LaFave wrapped up their presentation with three things you can do right now to ensure your documentation is defensible:

1. Review your clinic’s current documentation processes to ensure that you’re capturing the right data at every point in the patient’s lifecycle to improve patient care, cover yourself legally, and increase your marketing fodder.
2. Establish a plan for performing regular self-audits (better you than Medicare), so you know you’re clearly documenting the who, what, when, where, how, and why of every patient visit.
3. Use the findings from your process reviews and self-audits to set goals and implement necessary changes, thus ensuring that you’re continually improving.

Looking for more tips to ensure your documentation is defensible? Check out this post, and while you’re there, download your free copy of our 10 super-simple steps for creating defensible documentation at every patient visit.