What Makes Documentation Defensible?

Does talking about documentation make you want to cover your ears and sing to block out all the noise? If you’re like most therapists, the answer is a resounding ‘Yes!’ I think it’s safe to say that most of us became therapists because we wanted to improve the lives of our patients, not spend hours in front of a laptop writing detailed documentation notes.

But the reality is that documentation is vital, and it’s more than just a requirement to get paid—it’s a requirement for ‘keeping’ your money! Providers of rehabilitation services sign agreements with payers to abide by their rules and requirements of medical necessity and documentation as a condition of payment. 

What Is Defensible Documentation, and Why Is It So Important?

Imagine this scenario: If a payer audits a rehabilitation provider and finds that the services do not meet the standards of what is medically necessary, they can demand the money be repaid to them. And what if that same rehabilitation provider then goes back to the therapist who provided those treatments and asks for the money they received for those services back? In other words, what if your ability to keep your wages hinged on whether your documentation stood up to audit standards years down the road? Would it change the way you approached documentation every day?

That’s the value of defensible documentation! Ensuring your documentation is defensible is not just a financial incentive; it’s also a professional responsibility. Think about it this way: You take your car to the mechanic for a tune-up, and receive a bill for $5,000. The only information you find on the bill of sale is ‘tune-up’ and the number of hours spent on labor. Would you pay $5,000 for a service you thought would only cost $500 without more information? Probably not. You would expect more details to justify why the mechanic is asking you for that much money and why it was necessary. Likewise, payers of healthcare services—and more importantly consumers of healthcare services—want to understand exactly what they are paying for.

 

How Do I Ensure My Documentation Is Defensible?

While we all bring our unique style to documentation, there are minimal standards we must meet. Medicare, for example, requires that services “be reasonable and necessary to the treatment of the patient’s illness or injury or to the restoration or maintenance of function” and that the activities performed “require the skills of a qualified therapist.” How do we translate that into accurate documentation?  

It Starts with the Plan of Care

It’s true that the initial Plan of Care is the most important aspect of defensible documentation. If you don’t make the case for skilled services within it, then everything that comes after it is at risk. 

Here are some key considerations:

  • What happened? Why is the patient referred to therapy or why does the patient present for an evaluation? Make the case for why the patient needs therapy services now.
  • Has the patient received treatment for this condition, impairment, or injury before? Don’t be afraid to talk about it. Include details of what has worked or not worked, and what impairments or injuries remain.
  • What did you find? Including objective measures to support the need for skilled services is critical to defensible documentation.
  • How do you plan to address the condition, impairment, or injury? Writing clear, concise, and measurable goals lays the roadmap for what comes next.

Describe Skilled Services on Each Encounter

 Start off by using ‘action’ words to describe your actions in detail.

  • Are they specific? Interventions must be specific to the condition, impairment, or injury. For example, do you start all your patients on the same set of exercises? If yes, why? Sure, there are some lower body exercises that are good for everyone to do on a regular basis, but if that’s not why the patient is seeking services, payers will be skeptical and you’ll need to justify why you prescribed them. 
  • Are they skilled? Yes, there’s that word again. Eyes typically glaze when therapists hear the term because they have heard it so often, but stop and think… what does it mean? Can you define it out loud? If you can, and you do that frequently, it should become easier to put it in your documentation. Demonstrating ‘skill’ in your treatment encounter notes means describing what you, the therapist, were doing during the treatment session. After all, that is what payers are paying for—the skills and expertise of a therapist. Documenting sets and reps of exercises, or the same education and training or cues on repeat, does little to support why the patient needed to seek treatment from a therapy clinic. 
  • Describe the patient’s response to treatment. Assessment on every visit is an important part of demonstrating why the patient requires the skills of a therapist. 
  • Make it patient-specific. Avoid canned phrases or cookie-cutter electronic health record (EHR) phrases, such as, “Patient requires ongoing skilled therapy to achieve goals.” Instead, provide detailed examples of how they are making progress and specifically what skilled therapy will be provided. 
  • It’s okay if the patient is not responding to treatment, but it does require modifying the Plan of Care to keep the documentation defensible.


Ultimately, your documentation tells a story, and can act as a valuable record between providers and payers about the patient’s care and outcomes. It also helps protect you financially and legally, and shows the value of the services you provide to your patients. So remember, you’re not required to look forward to each day of documentation. You’re still allowed to dislike it! But if you don’t take the steps to make your documentation defensible now, you’re going to have a very bad day if you need to justify your documentation years down the road.

Looking for help getting your documentation defensible? Learn more about MedBridge Documentation Education.