Outcome 4
Produce documentation to support the delivery of physical therapy services
Criteria
4.1.
utilize technology effectively and efficiently
4.2.
select relevant information to document the delivery of physical therapy care
4.3.
documentation is consistent with guidelines, format, and requirements of the facility, regulatory agencies, and third-party payers
4.4.
documentation is accurate, concise, timely, legible, and grammatically and technically correct
Reflections...
Documentation through the use of SOAP notes is an important part of PT services. Not only do our notes document the care the patient is receiving so that their POC can be implemented, continued and progressed in subsequent sessions, but it is also a legal document and a key part of being reimbursed for services. "If it isn't written, it didn't happen" is something we heard often. It is imperative to be accurate and concise while using proper terms but avoiding too many acronyms. It is also important to use correct billing codes, not only for accuracy of billing but also for integrity in not overcharging the patient or their insurance company. One of the challenges I have faced in my clinical rotations is having to learn a new system for e-documentation at each site. I did learn that the clinic that hired me will be using Web PT which we used for Keep Stepping! The CI at my second rotation said I do a great job at documenting. My challenges are being more concise and increasing my speed.
Below is a SOAP note from my Keep Stepping client that was completed using Web PT.