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How to Capture the Perfect Daily Note in 60 Seconds

If you’re a therapist who loves writing patient care notes, this message is not for you and continue on your journey towards literary perfection! For the rest of us, it’s extremely frustrating to constantly be reminded of all the ways we need to improve our documentation in order to demonstrate medically necessary therapy services. Enough is enough – regardless of whether writing by hand, using a dynamic EMR platform or even dictating through an AI-powered software program, it’s time to put this challenge to bed.


In the next few moments, you will learn exactly what is required and how to physically accomplish this elusive goal. First, let’s review where documentation standards come from and how they impact our learning curve.


Person typing on a laptop

Resources for Documentation Standards

As a student physical therapist, we don’t receive a standard golden guide on how to document therapy treatments because we learn this skill from our clinical instructors. Depending on the practice setting, this acquired knowledge could vary dramatically. The first place to look is the most influential resource, Medicare: Chapter 15 Benefit Policy Manual.


Next, LCD (local coverage determination) outlines limited coverage, but with significantly more details that help guide documentation for outpatient physical therapy.


We also can’t forget Medicare contractors like Noridian who post their documentation standards.


Then we need to look at the largest commercial payors and what their benefit plans require. United Healthcare for example lists the following guide for PT/OT/Speech Therapy.


Our professional APTA organization, of course, also provides a variety of documentation resources and guidance.


And finally, we have the most underutilized ongoing resource available (because they don’t record their webinars) from the National Government Services.



Interpreting the Standards

Now that you have references, the trick is interpreting what all of this means. A certified healthcare auditor or an insurance company representative reviewing your documentation can help with this. If you already had the privilege of such an interaction it’s as if you’ve been given the perfect ab workout in 7 minutes, and then hear Ben Stiller from “There’s Something About Mary” say, “unless of course someone else comes up with 6-minute abs.”


You probably know where I’m going with this. Below is an example of how to actually capture a perfect daily note in just 60 seconds.


4 Step Guide to the Perfect Daily Note

S:  Step 1) Guide the initial subjective response to treatment by asking your patient, “How are you feeling since our last therapy treatment?” This avoids the generic and unrelated subjective details we love to record. One sentence (with a subjective pain score) is all you need.


O:  Step 2) Objective data is captured throughout the treatment visit on flowsheets/activity logs. Objective data should not be detailed again so this section is already finished before you start the note.


A:  Step 3) The only section that truly captures our skilled clinical judgement is the daily assessment. In one or two sentences we need to describe the how and why of your treatment session. Stop regurgitating the details that have previously been recorded. In other words, there is zero reason to repeat the “what” details of therapy, since we already know that information which is located in the objective section. Here's an example describing the how and why:  


Example: Patient tolerated this therapy session well as evident by improved right lower extremity balance during dynamic stability training with less verbal and tactile cuing. No increase in right leg pain was reported and improved body mechanics was observed, which assisted with proper upright posture and no hip/pelvic compensations throughout therapy.   


P:  Step 4) The goals, plan of care and future treatment selection should not be changing daily if your evaluation is properly crafted with the necessary details, so this section is already complete.


If you’re looking for more examples of the types of quality sentences that can be used for every section of every note, our Resource Library has an excellent guide specifically designed just for outpatient therapists. Become a Risk & Compliance Analytics member to gain access to this content and much more in our Resource Library.  


Conclusion

Just three sentences are all it takes to capture a perfect daily note. You can sit in expensive lectures for 8 hours and learn this or with a clear and concise role-based documentation webinar for 45 minutes, but either way we need to connect the “how and why” of our skilled therapy services to each and every visit in order to justify to payors the value and skill set of our treatments. It’s time to stop complaining about documentation and just focus on how to communicate better in less time!  


Need Training for your Therapists?

Want to educate your therapists with the most affordable training on documentation? Contact us about our concise 45-minute role-based documentation webinar.



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/ 

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