We choose to devote our professional, and often times our personal, lives to physical therapy for one reason and one reason only—to help our patients experience life to the fullest. It certainly isn’t for the money, the prestige, or the title. And that’s why the fight for autonomy, direct access, and respect within the medical community is worth it—because every single thing we fight for ultimately benefits the people we treat.
But while most of us fight for what’s right, a few of us apathetically reach for what’s easy—for shortcuts, quick fixes, and cut-corners. That isn’t the PT way, though. Just like there’s no crying in baseball, there is no corner cutting in physical therapy. There are rules—rules to protect the patient, the profession, and your practice. In my 16 years as a physical therapist and as the co-founder of physical therapy EMR WebPT, I’ve encountered a handful of blubbering pitchers (i.e., therapists looking for a way around what’s right), and below is my blooper reel.
“Can I Do One-Minute Documentation?”
First, there’s absolutely no way to finish a comprehensive initial evaluation in less than five minutes. Second, if you are actually somehow accomplishing this feat of super-speed, you’re doing it wrong. Not just a little wrong, either—a lot wrong.
Your initial evaluation should be detailed and thorough enough so that when you or a member of your staff, a Medicare auditor, or your patient reviews your documentation, it makes sense. If you don’t know who you treated, what you did, or why you did it, your documentation is incomplete.
Everything we’re fighting for (if you missed this above: autonomy, respect, direct access) comes with responsibility and liability. Documentation is our safety net; our justification; our record of care; and ultimately, our CYO. It’s a legal document that substantiates our intention, our purpose, and our actions in the treatment of our patients. If you are unwilling to take on this responsibility, you’re missing the point; you’re jeopardizing the profession, your practice, and your patients. And for what? To save a few minutes? Err! Wrong answer.
“Which outcome measurements should I use?”
There are certain things learned in school that without continual practical application we’ve forgotten—the quadratic equation, every state capital, the structure of the feudal system—and that’s okay because, quite frankly, I don’t need to know the quadratic equation (unless I’m ever thrown into an impromptu mathletes competition). But this isn’t the case with outcome measurements.
Aside from the fact that this wasn’t just a measly formula learned in the midst of a grueling algebra class, outcome measurements are a pretty big part of your initial and ongoing PT education. So, you should know what they are and which ones to use for patient documentation.
“Can my patient fill out the subjective section?”
Ugh, no. Those are your notes. You’re the expert. And it’s your signature and license on those notes. When you sign a completed note as a physical therapist, you put your credentials on the line. Are you happy with your notes? Are they defensible and of the caliber of your practice?
Incorrect documentation places the patient and the profession in jeopardy. Take pride in your documentation, in everything you do as a physical therapist. Not documenting—or not documenting correctly—is, well, just plain lazy.
“Why doesn’t the assessment section auto-fill?”
Every so often I get asked if WebPT can carry over the previously completed Assessment portion to the current note. Nope. There’s no carryover allowed. The Assessment section must be unique every time—free form, flowing prose. This is your overall assessment of your patient from beginning to end, head to tail. It’s where you display your skills as a physical therapist. You should be able to read this section five years from now and still know that person. Be detailed and specific. After all, this serves as the basis for your plan of care.
“Why can’t I delete my notes?”
When documenting on paper, the proper way to delete anything is to strike a single line through the text, and then initial and date the strikethrough. Of course, some people probably think it’s easier to just crumple up the note and pitch it. No paper trail. Alas, that’s not actually allowed.
EMRs increase accountability, because they don’t allow for the deletion of notes. You can’t delete them, and we can’t delete them for you. If you need to make a change, add an addendum. It’s no big deal. And don’t leave notes just sitting there not finalized, either. Finalize, and then, if you need to, add an addendum. Trust me; if you get audited, you’ll be thankful you did.
“Can you create my goals for me?”
Defensible goals have two criteria:
- They should be functional, meaning they should contain a task you want the patient to be able to achieve (e.g., reach top shelf of cabinet; tie shoes; lift 2-year-old son).
- They should list frequency and duration. How long will this goal take to achieve in terms of appointment length and number of appointments?
Obviously, these criteria are fairly particular, so no; we can’t create your patient’s goals for you. And why would you want us to? This is your patient, and the goals you set will directly impact (hopefully improve) their quality of life. As a PT, you should want to create their goals; you should care. Not to mention that specific, measurable goals are monumental when it comes to being paid by Medicare.
Surprisingly, a lot of the examples I’m listing here all relate to things we learned in PT school. You devote an entire semester to documentation while in school, and if you ever need a refresher after graduation, there are tons of resources available. For example, the APTA carefully outlines how to create defensible documentation.
We all get the education. Don’t act like you don’t remember. And, if you really don’t remember, relearn it—now. Seriously, please do it now for the sake of professionals everywhere. You’re making us look bad.
There you have it: my corner cutting blooper reel. Fortunately, these examples are few and far between, and they definitely do not represent the majority. Hopefully, these give you more than a chuckle; hopefully, they strengthen your resolve and push you even further to strive for what’s right in the physiotherapy field. Autonomy, respect, and direct access will transform our industry and allow us the freedom to establish ourselves as the musculoskeletal experts. I think in return we can strike out the shortcuts and knock our documentation out of the park.
About the Author
Heidi Jannenga, PT, MPT, ATC/L
Heidi was a scholarship athlete at the University of California, Davis. Following a knee injury and subsequent successful rehabilitation, Heidi developed a passion for physical therapy. She started her 16-year physical therapy career after graduating with her Masters from the Institute of Physical Therapy in St. Augustine, Florida.
In 2008, Heidi and her husband Brad launched WebPT, the leading web-based Electronic Medical Record (EMR) and comprehensive practice management service for physical therapists. As the company’s COO, Heidi is responsible for product development/management, billing services, and customer support.
She now resides in Phoenix with Brad and their daughter Ava.