Documentation in Physiotherapy

Documentation is a clinical memory and guidance system which is based on the evaluation of patients, this includes:

I: History & Examination

II: Goals of the treatment

III: Treatment plan to accomplish short-term and long-term goals.

IV: Response of patient to our planned treatment.

V: Clinical decisions

VI: Prior level of function and present level of function after short-term treatment.

VII: Progress Note- With accurate objective findings of the patient and accurate words

VIII: Precautions, safety, and contra indications.

IX: Estimated time or duration for maximum recovery or restoration.

Essentials of Good Documentation:

1. Formulate notes in a timely fashion, preferably during or at the conclusion of each treatment session.
2. Stick to the facts without judging or editorializing.
3. Be accurate in the evaluation and planning of treatment
4. Be brief but informative to other team members
5. Be professional–use standard abbreviations–and correct spelling
6. Document physical impairments and the patient's ability to function correctly
7. Avoid vague terminology such as functional strength. It is better to write actual strength finding (Grade+) under the objective section–describing the patient’s status.
8. Add a separate piece of paper for the “Clinical impression section” to render your professional opinion.
9. Use standard assessment tools and standard clinical tests.
10. Document all Doctor's orders, precautions, and contra indicators.
11. Be realistic in Rehabilitation goals, treatment plan, and estimated length of stay of the patient.

Documentation as Legal Evidence

Documentation is also done to provide legal evidence as to exactly what took place during each therapy session and also to communicate with other health professionals.

Documentation serves another important purpose to JUSTIFY to the INSURERS that proper care was provided and DESERVES to be reimbursed.

Maximum Reimbursement of detailed information and the progress of the patient is thus required.

Neither healthcare providers, nor third-party payees, wish to leave their patients or clients at risk for further injury.

Therefore, in order to illustrate the patient at risk, performing functional activities, the patient or OT must document:

1. Ability to safely cross the street. In a study by ROBBINET and VONDRAN, the average ambulation velocity required to cross a street safely in a moderate-sized city was determined to be 190/ feet per minute. Does the patient meet or exceed that minimum safe speed for the width of the street?
2. Ability to exit a nursing home in a fire, can the patient safely negotiate the fire stairs (not the main stairs) in the nursing facility. Fire stairs usually have a higher rise than standard stairs for faster egress.
3. Ability to telephone for emergency assistance.
4. Ability to perform ADL while manipulating ambulation devices (i.e., Functional ambulation) rather than simply documenting the gait- deviations and level of assistance)
5. Ability to get in and out of bed
6. Ability to get on and off the floor. As can easily be seen documenting safety is akin to documenting functional ability.

By documenting safety, Physiotherapy recognizes that the main purpose of rehabilitation is to allow the patient to interact with the environment with a minimum of risk and that is covered under all insurance benefits.

Documenting Skills

Therapists are constantly being asked by third-party payers to demonstrate that they are providing skilled services to other patients.

Many denials of payment are based on the lack of skilled treatment perceived by the insurance reviewer.

Documenting skilled care does not involve long copious notes, which no one wants to write (or read for that matter).

To illustrate a simple objective portion of a progress note written for a patient with IMPINGEMENT syndromes is as follows:

S- My arm is hurting less especially when I put on my sweater. But I still can’t do what I want. Even driving hurts me.

• Alternating isometrics at 90 degrees with yellow theraband for GH Proprioception.
• Modified push-ups and rowing exercise to enhance proximal stability.
• The patient was instructed in an independent posterior capsule stretch.
• Begin Sahrmann lower trap exercises to promote muscle balancing
• Visual feedback is needed in the mirror for control of Scapulo humeral rhythm, as the patient continues to be upper trap dominant.
• 5 mts ice massage to control pain and inflammation.
• The patient is given a home program

The assessment portion should briefly recap the patient's progress and deliver the patient's professional opinion on the efficiency of the treatment plan.

The above note conveys skilled care notes should include short-term treatment goals.

Documentation Referrals:

A referral must be sent with the patient. Due to shorter hospital stays, patients are quickly being transferred from one healthcare provider to another.

For example–A patient with a HIP fracture is discharged from the acute care hospital in 5 days, the sub-acute rehabilitation unit (hospital) after 2 more weeks, the skilled nursing facility after four more weeks, and finally to home to be seen by another therapist.

In a perfect world way, the medical record would arrive with the patient at each level of care and provide the therapist with all pertinent data needed to treat the patient effectively, but this is not a perfect world.

It is incumbent upon the therapist at each level to pass along the referral to the therapist at the next level of the case.