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Defensible Documentation

No one decided to be a healthcare provider because they wanted to spend a large part of their day documenting. Therapists and other healthcare providers chose this profession because they wanted to make a difference in people’s lives. Unfortunately, there is no way around it. If we want to be good clinicians, it is equally as important that we are as good at documenting as we are at treating our patients.

 Documentation is important because it is the record of what is going on with the patient and what was done with the patient. If that record is not thorough, it may set healthcare providers up for legal action, poor communication (and poor results) with patients and other providers, and poor reimbursement.

 We can probably all come up with many excuses why our documentation is not up to par. However, with all the changes in healthcare (Affordable Care Act, Medicare Therapy Caps, G-codes), it is extremely important that our notes provide a clear narrative of what we have done with our patients. The alternative could be legal action or not getting paid…not to mention good continual care should another therapist have to provide treatment.

 The following links are very helpful in showing what should be included in healthcare providers’ documentation, specifically providers of rehabilitation. Take a minute of your time to look and make sure you are compliant with the ever-changing healthcare world.

 http://www.apta.org/Documentation/DefensibleDocumentation/

 http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/TherapyCapSlidesv10_09052012.pdf

 http://www.asha.org/slp/healthcare/documentation/

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