Most PTs in the United States still use a pen-and-paper approach to note writing.
We scribble all day long in between running to patient treatments.
Medicare only has these written notes to examine to determine if the physical therapy treatments are worth paying for.
What do most PT charts look like and what decisions do they reflect?
Get some perspective
Step back for a minute.
Stop writing your note.
Stop being a PT or PTA.
Look at your chart.
What does it look like?
Is it organized?
Neat?
Sequentially organized?
Are the most important documents on top?
Does it look like you chart is designed for fast, efficient treatment?
Or, does it look like your chart is designed for fast, efficient decisions?
What do skilled physical therapy decisions look like?
Your skilled physical therapist decisions are what Medicare is paying for.
Treatment is secondary to your decisions.
Make the chart work for you.
Set up your chart so that evidence of decision-making is foremost.
Put your goals at the front of the chart.
Make decisions about goals in the daily note. If you still use a SOAP note the Assessment portion should reflect progress towards goals.
Make your initial measurements accessible. Put your dictated Plan of Care where you can get to it easily (hint: not at the back of the chart).
Two types of measurement need to be accessible:
1. Impairment in body structure and function (ICF)
2. Activity and participation limitations (OPTIMAL)
Put these near the front of the chart.
Some therapists feel that the back of a double-sided, flip-type paper chart is just as accessible by grabbing the whole stack of paper and flipping it up.
Perhaps it is.
I think that putting your goals and measurements at the back of the chart however sends the subtle message that you see writing about goals as less important.
Goals are less apparent and less evident at the back.
The presentation of your chart should reflect your intent.
What is your intent?
Decisions or treatment?
Decisions are more defensible.
*****
To get an incredibly detailed, voluminous, technical and shelf-worthy resource on physical therapy do-it-yourself Medicare compliance go to the
Compliance Program for Individual and Small Group Physician Practicesby the Office of the Inspector General.
To get a compliance program written by a physical therapist for physical therapists go to
BulletproofPT.comwritten by Tim Richardson, PT.
