In the work life of a physical therapist, the importance of documentation cannot be stressed enough. The main purpose of accurate and complete physical therapy documentation is to maintain continuity and quality of patient care among different providers.
Medical records and physical therapy documentation should be complete and legible at all times. Gone are the days when medical records are done by hand so legibility might not be an issue anymore. Conscious effort must be made to maintain completeness of patient records.
Dates and reason for the patient encounter, medical history and tests, initial assessment and a plan of care, are important components of a thorough physical therapy documentation. These information are needed since they also support the medical necessity of the procedures provided by the therapist to the patient. Medical necessity is required to ensure reimbursement by insurance payers.
Any diagnoses, past or present, should be accessible to current medical providers. These diagnoses might or might not affect the effectivity of the current care plan of the patient. In some cases, previous diagnoses will influence the current care plan so it needs to be included in physical therapy documentation.
When requesting for tests, labs and other measures, it’s need or the reason has be clear and stated in the physical therapy documentation. Requesting only for tests that are necessary will save the patient unnecessary stress. Unnecessary fees associated with those tests can also be avoided.
A written plan of care is an important addition to the physical therapy documentation. Referrals and consultations, if any, should be indicated. Patient and family education is also important to note as well as specific instructions for post care follow up.
Other pertinent data that should be found in the physical therapy documentation are factors that affect the health risk of the patient. Patient progress reports, response to procedures, any changes in diagnosis and treatment and even the patient’s non-compliance to the plan of care has to be documented. These factors are important since they affect the overall result of the plan of care.
Another important thing that must not be forgotten in any entries of a physical therapy documentation is the date and signature of person’s involved. As notes get added to the records, keeping track of who added those notes should be tracked.
Physical therapy documentation can be made simpler when one follows a logical flow to it. Only those who are directly involved to the patient should update it to avoid any errors and inaccuracy.