The document outlines best practices for defensible documentation in physical therapy to ensure accurate patient records and compliance with regulations. It emphasizes the importance of thorough documentation to protect therapists from legal risks and malpractice claims, citing examples of cases lost due to inadequate records. Recommendations include maintaining legibility, justifying treatment and outcomes, and ensuring entries meet legal and professional standards.

1. Best Practices for Defensible
Documentation in Physical
Therapy
Medical transcription outsourcing can ensure the
precise capture of the patient’s health story and ensure
integrity in physical therapy records.
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United States

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When documenting care, physical therapists should be knowledgeable about the
implications of electronic health records (EHRs), especially the increased
regulatory risks related to coding, patient safety, and malpractice. Many physical
therapists leverage the benefits of medical transcription outsourcing to ensure
accurate and prompt EHR documentation. Maintaining adequate, defensible
medical records is crucial for patient safety and for physical therapists to
demonstrate compliance and avoid malpractice liability. The American Physical
Therapy Association (APTA) stresses that creating “documentation throughout
the episode of care is a professional responsibility and a legal requirement”. Let’s
take a look at the best practices for defensible documentation in physical therapy
and how therapists can demonstrate integrity in practice through documentation.
According to the APTA, proper documentation of services is crucial for the
following reasons:
• Serves as a record of patient or client care, including a report of the
individual's status, physical therapist management and outcome of physical
therapist intervention.
• Serves as a tool for the planning and provision of services and a
communication vehicle among providers.
• Demonstrates the physical therapist's abilities, unique body of knowledge,
and services provided.
• Demonstrates compliance with federal, state, payer, and local regulations.
• Provides an historical account of patient and client encounters that can be
used as evidence in potential legal situations.
• May be used to demonstrate appropriate service utilization and payment
for many payers.
Defensible cases where the provider apparently delivered excellent care have
been lost or settled because of poor documentation. In 2016,
www.beckersspine.com reported on how lack of proper documentation was one
of the reasons that led an Oklahoma orthopedic practice to pay about $1.54
million to settle a civil claim suit.
A physical therapy claims case study published by the Healthcare Providers
Service Organization (HPSO) in 2006 also shows how inadequate documentation

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proved the culprit in a case involving a woman who received physical therapy
treatment following surgery to her ankle. After leaving the physical therapy
center, the patient reported a burn on her ankle at the site of the heat treatment.
The medical malpractice claim led to settlement and legal costs for the physical
therapist. The Risk Management comment was that there was no documentation
to explain the patient's severe burn or to indicate the defendant physical
therapist checked the plaintiff's skin before, during and after the heat therapy.
Defensible physical therapy documentation is that which can stand up to scrutiny.
The documentation will be able to justify and support the provider’s diagnosis,
plan of care, and thus, their payments. But what are the qualities of defensible
medical records? How can you know if your medical record documentation is
thorough and can face scrutiny? An article entitled “The Well-Written Record”
published in Rehab Management lists nine basic rules of good documentation:
• All entries must be legible.
• The diagnosis should clearly justify the need for rehabilitative services, or
the evaluation should indicate specific limitations and/or functional deficits.
• The findings reported should support the estimated frequency and duration
of care.
• A plan of care and measurable goals should be documented.
• Treatment provided and amount of time spent administering specific
procedures or modalities should be specified. Each treatment note should
justify the number of billed units.
• The patient’s outcomes should be documented on a regular basis and
justify the need for continued skilled therapy. The documentation should
include changes made to the treatment plan and new physician orders.
• The documentation should include the subjective comments of the patient
or caregiver during the course of treatment, with regard to progress made,
unusual occurrences, or complaints.
• The name and professional designation of the person providing the service
should be stated at the end of each entry.

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• The discharge summary should include the patient's chief complaint,
diagnostic findings, treatment administered, patient’s response to the
therapy, and recommendations on discharge.
In addition to this APTA advises providers to include the patient’s full name and
id, document every visit/encounter, include information of a patient’s
cancellations of appointments and/or refusal of treatment, ensure that the entry
is made appropriate security and confidentiality provisions, include adequate
identification of the patient/client and the physical therapist, and/or physical
therapist assistant, and date and validate all entries with all information about the
the provider as required by state law.
A paper published in Innovations in Clinical Neuroscience discussed the legal risks
specifically associated with EHR documentation. These include issues related to
templates, metadata, data overload, overreliance on entries made by other
providers, and input errors. The article recommends that providers scrutinize
their documentation carefully and review all entries before finalizing them.
The Rehab Management article provides a list of questions that physicians can
ask to see if their documentation meets the requirements for patient safety and
physician defensibility:
• Would the documentation stand up to a patient’s claim of injury during a
visit?
• Is the documentation comprehensive enough to recall events of a particular
encounter 2 to 3 years after the fact, and protect the provider against
questions and/or possible legal proceedings?
• Does the documentation provide proof of the patient’s need for skilled
physical therapy services on a continual basis, and justify the number of
visits, services provided, and claim submitted for reimbursement?
• Can the terminology and abbreviations in the documentation be
understood by a nonclinician rendering payment, treatment, and
authorization decisions?

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• Does the chart provide an accurate picture of the care rendered as may be
required by a third party?
• Do you frequently end up writing letters of appeal or spend an undue
amount of time on the telephone interpreting documentation to a
reviewer?
When it comes to ensuring quality patient records in physical therapy, the
support of an experienced medical transcription company can prove invaluable.
Reliable companies specialized in physical therapy transcription service are
dedicated to advancing patient safety and therapists’ integrity through the
precise capture of patient information in the electronic health record.