Documentation Guidelines and Principles

Guidelines for Documentation Frequency & Responsibility

• Documentation must occur for every treatment session.
  • A formal progress note is required each visit.
• Responsibility for writing the note
  • The clinician who actually treated the patient writes the note.
  • In some clinical settings, a supervising therapist must co-sign notes written by a student or assistant.
• Governing sources that mandate or influence frequency/content
  • \text{Insurance companies} (payment justification)
  • \text{Facility/department policies and standards}
  • State practice acts and federal regulations (e.g., Medicare)

Core Legal Principles of Documentation

(These 7 pillars apply to every entry.)

• Accuracy
• Brevity
• Clarity
• Demonstrated Skilled Need
• Proper Date & Legal Signature
• Use of Black, Non-erasable Ink
• Timeliness

Principle 1 – Accuracy

• Never falsify, exaggerate, fabricate, or omit information.
• Include all information pertinent to the patient’s care—even if it is unfavorable.
• Examples of accurate phrasing
  • "Pt required \text{min asst} to elevate LLE onto R knee in sitting."
  • Avoid vague statements like "patient did well" without data.

Principle 2 – Brevity

• Use short, concise sentences that capture only information relevant to treatment effectiveness.
• Highlight changes & improvements in functional abilities rather than repeating baseline.
• Caution with abbreviations
  • Because common abbreviations can carry multiple meanings, overuse can lead to misinterpretation.
  • When in doubt—spell it out.

Principle 3 – Clarity

• Write so that a reader can “visualize” the patient.
  • e.g., "In sitting, client grasps pant leg to lift and place L LE on R knee to reach L shoe."
• Employ correct punctuation, grammar, and spelling—errors can create legal vulnerability.
• Break content into logical sections (Subjective, Objective, Assessment, Plan) to improve readability.

Principle 4 – Skilled Need

• Documentation must make it obvious why a licensed/skilled clinician is required.
• Contrast examples:
  • NON-skilled: "Pt amb’d 50 ft with walker & \text{min asst}."
  • Skilled: "During gait training, pt amb’d 50 ft with RW while receiving verbal cueing for correct \text{2-point} gait sequence and \text{min asst} for occasional loss of balance. Pt demonstrated proper sequence 50\% of the time."
• Education points
  • Record the content of patient/family education (e.g., body-mechanics, energy conservation).
  • Document the patient’s demonstrated return of the skill to prove learning.
  • Note whether additional instruction is required and why.

Principle 5 – Date & Signature

• Every entry must include:
  • Full date of service (e.g., {8/30/05}) and, when necessary, the exact time.
  • Legal signature followed by professional title and license number.
  • Example formats
    • "Jane Doe, PTA, Lic# 12345"
    • "John Smith, PT, Lic# 67890"
    • "Sam Student, SPTA (cosigned by …)"

Principle 6 – Black Ink & Error Correction

• Use only permanent, black, non-erasable ink to eliminate opportunity for alteration.
• Error protocol
  • Draw one horizontal line through the mistake, write "error," initial, and date.
  • Do not erase, use correction fluid, or leave blank spaces.
• Never leave empty lines at the end of an entry; draw a diagonal slash or write "E.O.N." (end of note).

Principle 7 – Timeliness

• Document ASAP after treatment so details are fresh and legally defensible.
• For facilities with BID (twice-daily) treatments
  • Clearly distinguish entries by including both date and session time ("AM" or "PM").
• Late additions
  • If new information is recalled after signing, append an addendum:
  • Label it "Addendum to PT note {8/30/05}," include the new information, then sign/date again.

Practical “Do’s & Don’ts” Cheat Sheet

• DO
  • Write legibly and objectively.
  • Quantify everything you can: distance (ft), assistance level, repetitions, % accuracy, pain ratings.
  • Make clear links between impairments, functional limitations, and treatment choices.
  • Use headings (S, O, A, P) for fast review.
  • Justify continued treatment or discharge clearly.
• DON’T
  • Copy-paste previous notes without updates.
  • Use unapproved abbreviations.
  • Omit patient response or progress.
  • Delay signatures—unsigned notes are legally invalid.

Ethical, Legal & Practical Implications

• Accurate documentation is the primary defense in malpractice claims.
• Quality notes influence reimbursement: payers need proof of skilled, medically necessary services.
• Good records facilitate interdisciplinary communication, continuity of care, and evidence-based practice.
• Failing to follow ink, timing, or signature rules can trigger audits, denials, or legal sanctions.

Quick Reference – Common Numerical Markers (format examples)

• Distance walked: 50\ \text{ft}
• Correct performance: 50\%
• Dates: {8/30/05} (use full \text{MM/DD/YY} or facility-required format)
• License # examples: 12345, 67890

Connection to Prior Coursework/Lectures

• Mirrors prior lessons on SOAP note structure and ICF model: document impairments ➜ activity limits ➜ participation restrictions.
• Reinforces professional ethics modules: veracity (truthfulness) & non-maleficence (preventing harm through accurate data).
• Complements risk-management sessions on HIPAA and secure record handling.

Real-World Relevance & Case Application

• Third-party payers routinely deny claims that lack clear evidence of skilled intervention—these principles directly impact clinic revenue.
• In legal testimony, your note may be Exhibit A; clarity and detail can determine case outcomes.
• Electronic Medical Records (EMR) embed many of these rules (e.g., time-stamped entries, locked signatures), but the clinician remains responsible for content integrity.