3 Ways to Change Behavior towards Physical Therapy Documentation Quality
Updated: Jul 21
Due to the overwhelming response of our prior post on “How to Capture the Perfect Daily Note in 60 Seconds”, a follow-up complete with foundational structure and professional insight feels appropriate. As a skillful physical therapist, communicating a plan of care to a patient who has a future marathon-like mission ahead of them is complex. Understanding the mechanism of injury, onset experience, as well as the prior medical, surgical, environmental, and psychosocial details that impact how a patient arrived at this time and place is very difficult to accomplish.
Documenting our medically necessary therapy services is no different. Every student and new or senior therapist all arrive from different experiences; however, are all expected to maintain and record minimum quality levels of documentation for every patient encounter?
As previously referenced, many excellent resources are readily available for public viewing, but the same question keeps being asked over and over again: “As an owner, how can I implement documentation behavior change systematically throughout my company without offending anyone?” The problem (as you may have already guessed) is not you, it’s them!
3 Ways to Change Behavior Towards Physical Therapy Documentation Quality Without Offending Anyone!
Establish clinical operational standards that are communicated to each and every therapist (regardless of full/part time status). Ensure that everyone plays by the same rules and is knowledgeable of what all clinical expectations/definitions are, what the clinical documentation standards are (for everyone), and when and how documentation reviews take place. Details should include:
Exact expectations per note type
Billing and coding definitions
Lines of service and safety procedures
Implement a robust compliance plan that is tailored to your practice. Anyone can “figure out” how to calculate your taxes these days with programs and software, but having an accounting strategy that speaks to the health and future of your practice is very different. Think of it like this. A Datsun and a McLaren both have four tires, but obviously only the McLaren wins consistently because that’s what it’s designed to do! If you need a compliance plan that’s designed for your practice, partner with therapy compliance experts who have a history of success instead of trying to build something from spare parts over the weekend. Not only will you save time and energy, but it’s a fraction of the price for the most comprehensive therapy content on the market. (link to the store or membership). Tools and resources designed to help therapy owners succeed should not be an urban myth.
Enforce the standards by following through with your compliance plan. Implementing routine clinical audits, preventative weekly operational tasks, workflows that allow patient or employee concerns and other areas of liability to be quickly addressed all solve the same compliance problems by reducing the impact before sparks turn into fires. By objectively enforcing your practice’s standards, you can tie behavior towards documentation quality to performance evaluations. Therapists who do well on their audits can be rewarded with merit increases or other incentives. On the other hand, therapists who fail to achieve standards can be identified for additional training.
If you’re frustrated with the revolving conversation about how to impact the documentation quality in your clinic, take a step back and ask yourself:
How serious is your compliance program?
Have I considered a different approach?
Why is everything so expensive?
It’s time to expect more quality content for less cost!
Working with a dedicated and certified compliance officer is more affordable than you think, especially when you need results and time matters. We are proud to be different because owners need every advantage they can get in the current healthcare environment.
Daniel Hirsch PT, DPT, CHA, OHCC, COCA is a physical therapist licensed in Connecticut, New Jersey, and New York with over 15 years of risk management and compliance experience. He is CEO of Risk & Compliance Analytics LLC, a comprehensive compliance solution for outpatient therapy practices. He has experience in both Property & Casualty and Life & Health Insurance, has served as the Chief Compliance Officer for large multi-state Physical Therapy practices, is an educator on Therapy Ethics and the Profession, and has numerous compliance and ethics certifications.
You can find Daniel on Linkedin: https://www.linkedin.com/in/daniel-hirsch-dpt/
Follow his company page on LinkedIn: https://www.linkedin.com/company/risk-compliance-analytics-llc/
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