Documentation

Efficient, point-of-care documentation improves patient care, incorporates third-party and compliance requirements, reduces audit risk, and enhances revenue.

Documentation shapes the process of clinical reasoning, and provides the justification for payment of physical therapy services. Physical therapists and physical therapist assistants should not underestimate the importance of complete and accurate documentation or the implications of deficient documentation in today's health care system, which relies on documentation to measure patient outcomes, the medical necessity for services, and the justification of the plan of care. Insufficient or absent documentation can result in reduced payment for services, poor communication among providers, risk management concerns, accusations of fraud and abuse, and most importantly, the impact the care of the patient/client. Understandably, documentation requirements represent a common complaint among physical therapists, who frequently feel it is, "the worst part of their day". Paper documentation, in addition to being typically insufficient, is inefficient, which means less time is available for patient care, practice growth activities, and time with friends and family.

Although no one can guarantee against being audited, experts, lead by Helene Fearon & Steve Levine, partners in Fearon & Levine, have designed a framework within OptimisPT for incorporating professional and third-party documentation requirements for all aspects of documentation, including initial evaluations, reevaluation, treatment notes, progress reports, and discharge summaries. Our unique system also ensures that the CPT codes that you submit for payment purposes have been adequately described in the documentation of therapy services, further guarding against the potential for adverse audit outcomes.

OptimisPT provides a foundation for sound documentation practices to assist you in justifying medical necessity and minimizing risk. OptimisPT effectively integrates evidence-based practice and compliance rules into an efficient, point-of-care documentation system that allows instantaneous reporting capability for both referring physicians and payors in the level of detail that they want or require. This means improved patient care, superior communication, enhanced revenue, and a better quality of life.

at Point-of-Care

The most effective time to capture patient and treatment information is at the point of care when the facts are fresh. Typically, therapists often delay patient-visit documentation until the end of the day, when memory of the patient encounter is strained and competing interests, such as going home, converge; these dynamics often lead to incomplete and inaccurate documentation and pose risk for inappropriate billing. Designed as a point of care documentation tool, OptimisPT facilitates effective and efficient data capture for proper documentation and billing at the point of care.