Legal Aspects of Documentation



Legal Aspects of Documentation




Documentation as a Legal Record


Documentation in a medical record is a legal document. A therapist should treat notewriting very seriously and understand that his or her notes may be scrutinized not only for payment of services, but also for legal reasons.


State practice acts define the scope of practice for PTs in each state (see Resources list at the end of this chapter). Therapists should be familiar with their individual state practice acts to be sure they are in compliance and that their documentation reflects practice that is within the legal description provided by their state. For example, if a state practice act requires a referral from a physician for a PT to practice, that information must be included in the medical record (regardless of whether it is required by a third-party payer).



KEY LEGAL ASPECTS OF PHYSICAL THERAPY DOCUMENTATION


Several key legal aspects pertinent to physical therapy documentation are outlined below:



• Legibility. Handwritten entries should be legible and written in ink.


• Dated. All notes must be dated with the date that the note was written. Backdating is illegal and should never be done. It is recommended that all notes be written or dictated on the date that an evaluation or intervention is performed. If a note is not written on the date, then both the date of the evaluation/intervention and the date the report was written should be indicated. For notes in an interdisciplinary medical record, the time of treatment should also be recorded.


• Authentication. All physical therapy documentation must be authenticated by a PT, or when appropriate, a physical therapy assistant (PTA). All notes must be signed, followed by the writer’s professional abbreviation, and dated. The American Physical Therapy Association House of Delegates (APTA HOD, 1999) has recommended use of standard professional designations: PT for physical therapists and PTA for physical therapist assistants (Figure 3-1, A).



• Degrees and certifications. The APTA supports the following preferred order when a therapist or assistant has additional degrees or certifications (Figure 3-1, B). These are not relevant legally but are important to promote consistent communication throughout the profession:



• PTA authentication. PTAs can typically sign only treatment notes; all evaluations must be written and signed by a PT. Depending on individual state practice acts, PTs may be required to co-sign each note written by a PTA.


• Student PT and PTA authentication. SPTs or SPTAs (individuals who are enrolled in a PT or PTA educational program) are allowed to write notes in the medical record. These notes must be signed and dated by the student and also must be authenticated by a supervising licensed PT or PTA (see also APTA Guidelines, Appendix A) (Figure 3-1, C).


• Errors. If an error is made in a handwritten note or a printed copy of an electronic note, the therapist should place a single line through the erroneous word and write his or her initials near the crossed-out word. The date and time of correction should also be included (Figure 3-2).



• Blank lines or spaces. Blank lines or large empty spaces should be avoided in the record. A single straight line should be drawn through any open spaces in a report.


• Abbreviations. The writer should use only those abbreviations authorized by his or her facility (Appendix B provides a list of commonly used abbreviations in rehabilitation settings). Abbreviations should be kept to a minimum; if in doubt, write it out (see Chapter 2 for information on using abbreviations).



INFORMATION TO INCLUDE IN A NOTE


From a legal persepective, the medical note should provide a record of everything that was done during the therapy session. This includes what the patient did (e.g., exercises, activities) as well as specific interventions performed by the therapist (e.g., gait training, electrical stimulation). This information is not always necessary for purposes of payment, but therapists should be careful to document comprehensively for legal purposes. A therapist must ask whether his or her note, if referred to at a later date, would clearly establish what was done and why. If a therapist is being sued for malpractice, for example, the medical record will be scrutinized to determine what interventions were performed, what the patient was able to do, and how the patient reacted to the interventions.


Only information that is directly relevant to the patient’s medical condition, prognosis, or intervention plan should be documented in a medical record. Sometimes conflicts or personal issues arise between therapists and patients, and between patients and their physicians or other medical professionals. Generally, information of this nature should not be included in clinical documentation. Box 3-1 contains definitions of key documentation terms.



BOX 3-1   Important Definitions




Audit: a detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of medical care.


Authentication: identification of the author of a medical record entry by that author, and confirmation that the contents are what the author intended.


HIPAA Privacy Rule: a component of a law passed in 1996 that is designed to protect the privacy of health care data and to promote more standardization and efficiency in the health care industry.


Informed consent: a voluntary, legally documented agreement by a health care consumer to allow performance of a specific diagnostic, therapeutic, or research procedure.


Malpractice: negligence or misconduct by a professional person, such as a doctor or physical therapist. The failure to meet a standard of care or standard of conduct that is recognized by a profession reaches the level of malpractice when a client or patient is injured or damaged because of error.


Medical necessity: services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.


Notice of privacy practices (NPP): a notice or written document given to a health care consumer that explains the privacy policies related to his or her medical records. All patients must sign a statement acknowledging receipt of the NPP.


Third-party payer: an organization other than the patient (first party) or health care provider (second party) involved in the financing of personal health services.

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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Legal Aspects of Documentation

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