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Resources — 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), then yet again in Transmittal 63 (December 29, 2006).
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.
RCRI 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. 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 9 individual documentation templates
that include the following:
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Patient Initial Self Report of History and Health Status Questionnaire
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Initial Evaluation
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Plan of Care (Short & Long Version)
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Daily Treatment Note
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Progress Report
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Patient Self Reassessment for Reevaluation
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Reevaluation
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Discharge Summary
The RCRI Documentation Templates are available for purchase as a package.
The purchase price includes one hour of phone consultation to review the
components of the templates, answer any questions, and ensure the purchaser
has a clear understanding of how the templates can best be utilized specific
to the purchaser’s needs. The templates are provided electronically in both
PDF format as well as Microsoft Word format so that they can be modified for
your practice or facility’s specific needs. The RCRI templates can also be
individualized to incorporate a specific logo or practice information.
Although the templates are copyrighted by RCRI, they can be modified by the
individual practice/facility to include additional information or specialty
data. However, RCRI recommends that the basic template
information be retained to provide therapists the structure and appropriate
space to facilitate documentation of necessary information to support
medical necessity.
For additional information, including package price, or to order RCRI’s
Documentation Templates, contact us at
954-321-1008 or
stevelevine@rehabconsulting.biz.
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