Physical Therapists and Rehabilitation providers are subject to intense scrutiny and review by multiple regulatory agencies, from the Department of Health (DOH) and Independent Peer Review Organizations (IPRO) to Federal, State and County governments. Patient records and billing documentation are reviewed by insurance companies and government agencies assuring quality of care as well as fraudulent billing practices. Each time a review is conducted, the practice must open its doors and documentation to review, scrutiny as well as opportunities to improve the quality of care provided and the management practices utilized.
As young therapists in school, documentation is taught to be poof of intervention with the client which lends itself to legal review and standards. Providers and private practice owners must assure the highest level of care provided to clients, as well as sound thinking and careful documentation of this care. Without it, Physical Therapists and Rehabilitation providers open themselves to liability, poor quality of care and the possibility of legal fees and professional fines. In the most severe cases, the professional license is at risk.
There is no worse fear than a fear of being audited. However, with careful preparation and planning, audits can be used to the practice’s advantage to improve guidelines and standards. Educating staff regarding the standards to which they are help is paramount. Providing ethical and contemporary care in a caring and compassionate environment is the key to success. Documentation of these processes is the foundation to turning an audit from something to fear, into an opportunity to gain access to knowledge which will improve your practice and an opportunity to implement strategies for success.
Helpful hints for charting!
1. Informed Consent: HIPPA and Consent to Care policies must be reviewed with each client and kept on record to assure they have been made aware of their privacy as well as documented informed consent regarding care to be provided.
2. Chart Reviews: Do a self Audit!
a. Perform a Chart Review on each chart monthly to assess the quality of care provided and the proof of required treatment which follows the established plan of care. Review the record again prior to discharge to assure you have completed all documentation and completed all follow through discussed with the client.
b. Include your signature with professional letters and license number on each note and watch the use of abbreviations! Anyone should be able to understand the documentation if reviewed by the client, insurance company or a legal team. Assure a Physician’s order is complete with appropriate documentation of the plan of care.
c. Use a teaching record consistently and ongoing. Therapists have the important role of educating clients to assure they are able to continue their recovery without therapeutic intervention.
d. Put copies of the client’s Home Exercise Program (HEP) in the chart and document the teaching in the teaching record. The HEP should include your name and a way for the client to contact you with questions as well as a clear list of instructions. The client’s plan of treatment should reflect progress towards established goals. Not just “continue treatment.”
3. The Team Approach! Document all phone calls in your daily notes to assure and demonstrate transdisciplinary treatment and care. Document the method, date and time with which you communicated your reports to attending and consulting team members. Show transdisciplinary treatment by noting the list of providers who have received a copy of your reports and the method by which you sent the report (ie: fax, email, USPS, etc.).
4. Schedule paperwork time! Getting behind in paperwork is both stressful and lends itself to an increased rate of errors.
Staying up to date on documentation is one of the single most effective tools in preparing for a Physical Therapy Audit. Documentation must substantiate care provided as well as link directly back to progress according to the Physical Therapy Plan of Care. With careful attention to the details of documentation, audits will become opportunities to invest in yourself and the advancement of your practice.