Documentation Templates

Methods of documenting range from a fully integrated Electronic Medical Record (EMR) to pen and paper. The content of the documentation also varies according to the clinician’s personal style of communication and can also be influenced by the setting in which the services are delivered. Clinicians and facilities spend countless hours designing, developing, testing, modifying, redesigning, and redeveloping forms and templates to assist therapists in documenting the services they provide in the most complete and efficient way possible. Part of this challenge is that clinicians document for many audiences, including themselves, their patients, referral sources, third party payers, the legal system, and to justify the services provided. Appropriate documentation supports positive outcomes of the interventions provided, and can justify the clinician’s participation as an essential component of the healthcare delivery system.

In February of 2006, Medicare published Transmittal 47, which for the first time outlined the minimal documentation requirements for outpatient physical therapy services provided under the Medicare program. Medicare then revised these requirements in Transmittal 52 (June 30, 2006), then again in Transmittal 60 (November 9, 2006), yet again in Transmittal 63 (December 29, 2006), and most recently in Transmittal 88 (May 7, 2008). Keeping current with these documentation requirements entails constant vigilance and extensive review of ongoing CMS communications and incorporation of these requirements into components of clinical documentation. It is critical that therapists ensure that their documentation justifies medical necessity for the services they are providing and for which they are billing any third party payer.

Fearon & Levine has developed documentation templates that have incorporated the requirements for documentation under Medicare as well as components of the Guide to Physical Therapist Practice (APTA, rev. 2002). The templates have been designed predominantly for the musculoskeletal patient but can be easily adapted for the neurologically involved patient. Since 85% of physical therapists and physical therapist assistants currently hand write their documentation, the current version of the templates is designed for use in clinics where the primary method of documentation is handwritten notes, although they can easily be incorporated into a dictation or voice activated software process. There are 10 individual documentation templates that include the following:

• Patient Initial Self Report of History and Health Status Questionnaire
  
• Initial Evaluation (with and without Falls Assessment)
  
• Plan of Care (Short & Long Version)
  
• Daily Treatment Note
  
• Progress Report
  
• Patient Self Reassessment for Reevaluation
  
• Reevaluation
  
• Discharge Summary

For more information, contact us at templates@FearonLevine.com, or 954-745-7907.

To purchase Fearon & Levine’s Documentation Templates Click Here.