The answer to the question, “Do we need to document daily when providing therapy services?” seems like it would be a no-brainer, right?
Well, it may seem like a no-brainer to many of us in practice, but for some therapists, this is a genuine question….and it is popping up regularly these days!
In the course of 1 month, this exact question and/or this topic came to our attention multiple times in our consulting practice. Something must have happened out there in the SNF world to trigger an influx of this specific question. But what? Well, we may have some insight and hopefully some answers.
Today we will share with you an actual question {see below} submitted to our Just Ask Q&A Forum, along with our response. The question is concerning in that the therapist writing in reported that she was informed by her company that therapists would no longer be writing daily notes. “Stop,” they said. “Less is more,” they told her. “Only document if something {bad} or {important} happens.” “It takes up too much time,” she was told.
This can’t possibly be about productivity, can it?? With a little more digging, we discovered that this directive has come down from administration in a few of the “big” chains. Hmmmm… It looks like some companies did not do their research!
In our effort to support therapists, we have a few things to say about daily documentation and the regulations to back them up! YES, daily documentation IS required. Read on…
Q: Our Company just told us we are not allowed to write daily treatment notes any more. We were instructed to only write a note if there was an “event” or if something “atypical” happened. Is there a regulation that backs this up? I’m a bit hesitant to stop doing this. (Some details were left out of the original question to protect the writer)
A: This question comes up a lot but what was unique about your question was that you were doing daily notes and your company told you to stop. This is concerning as a licensed professional. Remember the old saying “if you didn’t write it, then it wasn’t done?” Well, that still applies, no matter what anyone tells you! Go with your gut on this one!
Here is some information to back up our answer and to validate your concern with this topic!
- Medicare Part B requires a Daily Treatment Encounter Note for reimbursement as per the Medicare Benefit Policy Manual. Quoted from the Manual, “The purpose of these notes is simply to create a record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim. Documentation is required for every treatment day, and every therapy service.” This is from the Medicare (Part B) Manual, Chapter 15.
- Medicare Part A has documentation requirements in place to justify daily skilled care. Chapter 8 of the Medicare (Part A) Manual states that nursing and therapy are to record the skilled service provided and the “resident’s response to the skilled service” on each visit.
- Our professional associations (APTA, AOTA, ASHA) describe writing a daily treatment note as a “Standard of Practice.” These associations are where different insurance companies look to for guidance when comparing our documentation in the chart to “how our associations say it should be.’
- Insurance companies {including Medicare} require documentation on what you did, why you did it and the outcome for each patient. After all, they are paying for a service you are providing so how else would they know that, #1 You provided the treatment, #2 The patient benefited from it and #3 What your plan is for your patient.
- If you are the PT/OT responsible for progressing the patient, as well as writing a progress report, you will rely on daily notes to properly oversee treatment.
- What if you’re out sick tomorrow??? How would someone coming in to cover for you know what you were working on and how the patient had been tolerating the treatment? Or what if you were a per diem therapist? Wouldn’t you want to see a past treatment history? Without this written information the patient is potentially at risk for harm.
- CYA (Remember that?) Picture yourself on the “stand” in the middle of a lawsuit being questioned as to what you did on a certain day. You say, “I need to refer to the record”….oh wait…there is NO RECORD! Yikes!
- And if nothing in 1 through 7 has grabbed you…Here’s a biggie…Lack of documentation for treatment may be considered professional misconduct depending on your State Practice Act. Here’s an excerpt from NYS PT Practice act: “Failing to maintain a record for each patient which accurately reflects the evaluation and the treatment of the patient… is considered Unprofessional Conduct under Rule 29 of the Board of Regents.” What does your Practice Act say?
In addition to the answer given to the therapist above, there is sooo much more to lose if we don’t document. 
How will we support our billing claims? Heard of the False Claims Act? How will we show Medicare that our services are reasonable and necessary? How necessary can they be if we don’t even document them?
Daily, thorough documentation is key to a successful and safe therapy experience for you and your patients. There is no weight on the side of the argument to “stop documenting daily.” What would the argument be? It cuts into productivity? It takes too long? It might show duplication of services? It might not show progress? Seriously?
Please….document….daily….
In the end, if you are still not sure, you can always look to your State Practice Act {law} or professional association for guidance on what you should do.
Documentation should be Your decision. After all, it’s Your license!!
So please don’t be fooled out there! Even if you have to keep your own notes for each treatment….Write On!
In Your Corner,
Dolores
Want more information on Documentation?
Agreed, daily documentation is imperative. However, there are legitimate shortcuts to daily documentation that preclude the need for an actual daily narrative. I can’t help but wonder if some of the clinicians writing in are mistakenly inferring that the directive to forgo the daily “note” means don’t document at all. I have heard debates about how much daily documentation is “enough” in every rehab department over a span of 10 years as a registry and per diem therapist. The consensus is usually, but not always, that less is more when it comes to daily narratives, especially for assistants, with high expected productivity levels.
In every billing system I have seen over the past 17 years, there is some sort of daily coding required for each visit. The CPT code defines the tx provided and number of minutes. There is usually a box to check or a code for patient response to tx (G, F, P). Sometimes there is a grid for daily updates in specific functional areas. Is this enough? On a day when the patient neither significantly progressed or regressed, the goals and tx plan remain appropriate and the medical condition is stable, it is arguably enough.
The weekly progress note is the appropriate place for extensive documentation, worded by a licensed therapist, to describe the patent’s response to tx techniques, to adjust goals, to justify the plan of care and to update the d/c plan. As a per diem therapist walking in to see a pt my first time, I rely most heavily on the initial evaluation, most recent weekly progress report and response to tx the previous day.
The weekly progress note is the appropriate place for extensive documentation, worded by a licensed therapist, to describe the patent’s response to tx techniques, to adjust goals, to justify the plan of care and to update the d/c plan. As a per diem therapist walking in to see a pt my first time, I rely most heavily on the initial evaluation, most recent weekly progress report and response to tx the previous day. Especially if I have to write a weekly progress report that day, I do not appreciate wading through lengthy daily narratives. Too often, these notes simply regurgitate the same “skilled terminology” phrases that managers have compiled using wording so stilted that it has to be copied and pasted because it would take forever to type. Notes like these are dangerous in a legal situation, because they can be hard to understand and easily misinterpreted, especially by a reader from outside the discipline. If I see a long daily note, my first impression is that either the patient had a breakthrough/ breakdown, or the treating clinician went overboard.
I tell my COTA’s that they only have to document to exception. * If a patient complains of pain, document initial assessment of pain, action to resolve it, and reassessment, etc.
* If a patient’s performance improves or declines, document that and the underlying cause.
* If nursing attention was required or there was a change of the patient’s condition, document it.
* If the response to tx was Fair or Poor, document consultation with the licensed therapist and/ or IDT on whether the pt continues as a good rehab candidate for the plan of care or requires re-assessment.
* If caregiver training was provided, document who, what, when, where, why and any handout issued.
In our current GG-code, RUG-level, insurance-driven model, it seems that we only get more complicated documentation demands every year.
To “stop documenting daily” is unthinkable. But to “stop writing daily narratives on every single patient” is doable and sensible if we are to keep our sanity.
Agreed, nothing wrong with brevity as long as: for Part A skilled care is shown, and for Part B CPT Codes are justified. 2-3 sentences in layman’s terms would be ideal.