Physical therapy documentation includes evaluations, daily notes, progress reports, and discharge summaries. These records support clinical decision-making, payer reimbursement, and legal compliance.
Accurate documentation must reflect medical necessity, functional limitations, and skilled intervention. Common challenges include time constraints and duplicate data entry. Modern EMRs streamline this through automation.
Why it matters:
Documentation protects clinics legally and ensures you get paid. It is the number one source of burnout, so efficiency is critical.
Pro Tip:
Docs done before dinner. Strong documentation focuses on function and progress, not volume of text.
FAQ
- How detailed should PT documentation be? Detailed enough to support medical necessity and skilled care. It also needs to follow compliance for a specific payer.
- What is "defensible documentation"? Documentation that clearly demonstrates the medical necessity of skilled care and can withstand scrutiny during an insurance audit.
- How long should a daily note take? With efficient software and workflows, a daily note should take only a few minutes to complete.
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