BLOGS
Unraveling the documentation puzzle for physical therapists and occupational therapists
Good documentation skills and appropriate documentation review skills are important for physical therapists and occupational therapists alike.
Written/Typed Documentation Skills:
For example in the state of New York for physical therapists therapists must:
Maintain written records for every visit or encounter with clients. Entries should be written in ink and signed by the licensee using full name and professional designation (e.g., PT or PTA) and date of service as well as:
- Reason for encounter, preliminary assessment, and subsequent disposition.
- Comprehensive evaluation of problem, including the interpretation of tests and measurements, to determine intervention and assist in the diagnosis and prognosis.
- Plan for service, including specific goals and the interventions related to each goal. If actions are delegated to another licensed professional, specify those tasks and how the patient’s progress will be assessed or reviewed. If plan is modified this should be noted along with recommendations for follow-up or other intervention.
- Date of service and intervention or treatment provided during each contact with client, including specific follow-up actions to be taken, if relevant.
Occupational Therapists in the state of New York must:
The Rules of the Board of Regents on Unprofessional Conduct require that Occupational Therapists complete and maintain accurate records for each patient. These records may include:
- prescription or referral for treatment
- documentation of findings from evaluation
- intervention plan
- treatment intervention
- patient response
- outcomes
- recommendations
** These documentation rules apply to outpatient rehabilitation therapy/medicare part B recipients. Subacute care/skilled nursing facilities treatment have different requirements and daily notes are not always required. States vary but typically daily documentation is required outside of a subacute rehab or skilled nursing facility. **
Documentation Review:
In terms of documentation review physical therapists and occupational therapists alike are required to review prior medical documentation before treating a patient.
- In acute care (inpatient or intensive care unit) in a hospital the therapist is required to view the patient’s medical chart to review the most recent nursing and doctor notes. The therapists are required to review the hemoglobin (HgB), and hematocrit (HCT) levels for acute patients and to review their most current vital signs. Therapists are required to review and understand the patient’s medical diagnoses and precautions that are in place for the patient. Therapists are also required to review the medications and have an understanding of side effects of medications.
- In outpatient therapy care, where patients bring themselves into the clinic or are brought in by others, therapists are also required to review prior documentation. For example, if the patient is a new evaluation the therapist needs to understand the medical prescription and any contraindications that are in place. Even if the surgeon does not write down specific precautions it is the therapist’s duty to contact the surgeon or doctor and to find out what is allowed and what is not.
** It is important to note that a lot of states have direct access to occupational therapists and physical therapists. This means that a therapist can see a patient for 10 visits or 30 days whichever comes first without a medical prescription. The therapist is responsible for finding out if there are any contraindications to their treatment either by contacting the physician or if the patient can provide this information. Therapists are not let off the hook with documentation review just because a patient comes in without a prescription. **
Documentation review and documentation skills are very important to have therapists complete thoroughly. Unfortunately, a lot of therapists forget to review medical charts, prescriptions, and contraindications before treating patients. This unfortunate mistake could be viewed as a deviation from the standard of care and would make the therapist liable for the incident that occurred.